| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
169 |
169 |
$192.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
65 |
$165.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
157 |
$48.50 |
| D0120 |
Periodic oral evaluation - established patient |
266 |
266 |
$39.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$21.75 |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$14.00 |
| D1120 |
Prophylaxis - child |
72 |
72 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
63 |
$0.00 |
| D1330 |
|
295 |
295 |
$0.00 |
| D1310 |
|
149 |
149 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |