| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
87 |
87 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
17 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$3K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
74 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
77 |
$960.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
43 |
$446.08 |