| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
53 |
49 |
$4K |
| D1206 |
Topical application of fluoride varnish |
132 |
129 |
$4K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
106 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
46 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
86 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$726.63 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$717.60 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$499.52 |