| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
279 |
70 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
54 |
$3K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
66 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D1206 |
Topical application of fluoride varnish |
55 |
54 |
$906.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
14 |
$315.90 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$280.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
28 |
$261.60 |
| D1330 |
|
43 |
43 |
$0.00 |