| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
413 |
412 |
$9K |
| D1110 |
Prophylaxis - adult |
195 |
195 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
372 |
372 |
$9K |
| D1120 |
Prophylaxis - child |
130 |
130 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$863.63 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$716.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
13 |
$192.51 |