| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
67 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D9920 |
|
17 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$519.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
42 |
$472.00 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
56 |
$464.00 |