| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
166 |
166 |
$17K |
| D1120 |
Prophylaxis - child |
100 |
99 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
32 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
26 |
$990.75 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$574.98 |
| D0330 |
Panoramic radiographic image |
17 |
16 |
$299.98 |
| D0274 |
Bitewings - four radiographic images |
168 |
167 |
$184.36 |
| D0120 |
Periodic oral evaluation - established patient |
187 |
186 |
$159.57 |
| D1206 |
Topical application of fluoride varnish |
263 |
260 |
$13.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
412 |
226 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
86 |
85 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
239 |
$0.00 |