| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
317 |
317 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
256 |
$4K |
| D0274 |
Bitewings - four radiographic images |
228 |
228 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
382 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
265 |
$789.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
26 |
$675.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$436.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$160.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$140.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$100.00 |
| D0601 |
|
13 |
13 |
$50.00 |