| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
481 |
477 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
473 |
$4K |
| D0330 |
Panoramic radiographic image |
216 |
215 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$1K |
| D2332 |
|
69 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$925.75 |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
259 |
$711.00 |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$292.50 |
| D0603 |
|
90 |
88 |
$30.00 |