| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
103 |
99 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
30 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$743.47 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
41 |
$620.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$503.25 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$437.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
16 |
$214.63 |