| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
138 |
138 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
210 |
$5K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$898.22 |
| D9920 |
|
12 |
12 |
$624.00 |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$538.80 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$206.81 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$130.17 |