| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$587.00 |
| D1999 |
|
13 |
13 |
$520.00 |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
92 |
$406.00 |
| D1330 |
|
90 |
90 |
$192.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$137.00 |
| D1120 |
Prophylaxis - child |
59 |
59 |
$76.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$45.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
80 |
$15.00 |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$0.00 |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$0.00 |