| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
162 |
162 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
28 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$694.84 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$485.04 |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$194.67 |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$69.91 |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
64 |
$0.00 |