| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
103 |
100 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
24 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
72 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
79 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
102 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$600.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$409.00 |
| D0330 |
Panoramic radiographic image |
18 |
15 |
$277.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
42 |
$248.20 |
| D0274 |
Bitewings - four radiographic images |
19 |
15 |
$127.60 |