| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
242 |
224 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
166 |
76 |
$12K |
| D1351 |
Sealant - per tooth |
422 |
95 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
470 |
431 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
108 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
712 |
412 |
$959.98 |
| D0274 |
Bitewings - four radiographic images |
339 |
312 |
$722.00 |
| D0220 |
Intraoral - periapical first radiographic image |
509 |
457 |
$319.00 |
| D1330 |
|
458 |
422 |
$147.00 |
| D9215 |
|
136 |
98 |
$0.00 |