| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
34 |
$1K |
| D1206 |
Topical application of fluoride varnish |
46 |
41 |
$924.55 |
| D0330 |
Panoramic radiographic image |
30 |
28 |
$901.08 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$684.45 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
23 |
$512.40 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
32 |
$397.36 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$311.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
21 |
$197.33 |