| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$876.00 |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$724.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
112 |
$669.23 |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
133 |
$501.38 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$494.41 |
| D1330 |
|
135 |
134 |
$491.91 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$312.00 |
| D0603 |
|
68 |
68 |
$52.00 |
| D1310 |
|
120 |
119 |
$0.00 |