| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
199 |
199 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
324 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
230 |
230 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
63 |
$2K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$1K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$951.60 |
| D1351 |
Sealant - per tooth |
102 |
27 |
$900.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$595.00 |
| D1353 |
|
77 |
13 |
$570.00 |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
246 |
$530.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
227 |
$346.35 |
| D9211 |
|
17 |
16 |
$255.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$150.00 |