| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D1110 |
Prophylaxis - adult |
22 |
22 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
82 |
$1K |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$895.19 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
73 |
$757.89 |
| D0274 |
Bitewings - four radiographic images |
21 |
21 |
$568.07 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$198.00 |