| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
378 |
340 |
$3K |
| D0274 |
Bitewings - four radiographic images |
168 |
148 |
$2K |
| D1206 |
Topical application of fluoride varnish |
195 |
180 |
$2K |
| D1120 |
Prophylaxis - child |
111 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
495 |
247 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
101 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
86 |
$1K |
| D0330 |
Panoramic radiographic image |
90 |
82 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
64 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$867.07 |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$645.88 |
| D0272 |
Bitewings - two radiographic images |
30 |
26 |
$333.97 |