| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
207 |
207 |
$4K |
| D9630 |
|
259 |
257 |
$3K |
| D1206 |
Topical application of fluoride varnish |
220 |
219 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
228 |
227 |
$2K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
57 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
130 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
194 |
$973.51 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
39 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$0.00 |