| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
26 |
$5K |
| D1110 |
Prophylaxis - adult |
153 |
153 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$955.84 |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$150.43 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$91.27 |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
143 |
$22.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
95 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$0.00 |