| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
87 |
86 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
156 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
71 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$363.25 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$324.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$203.42 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |