| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
142 |
142 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$735.62 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$463.62 |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$218.68 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$102.47 |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$52.53 |
| D1206 |
Topical application of fluoride varnish |
143 |
143 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |