| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
75 |
75 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
356 |
356 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
16 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
457 |
167 |
$2K |
| D9430 |
|
12 |
12 |
$384.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |