| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
337 |
337 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
277 |
$10K |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$7K |
| D1120 |
Prophylaxis - child |
161 |
161 |
$5K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
14 |
$3K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$771.05 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$633.46 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$307.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$114.86 |