| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$6K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$5K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
133 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
18 |
$945.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$388.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
53 |
$347.68 |