| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
231 |
230 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
135 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
76 |
$6K |
| D0274 |
Bitewings - four radiographic images |
225 |
223 |
$6K |
| D1110 |
Prophylaxis - adult |
162 |
162 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
237 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
257 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
64 |
64 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
132 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$450.00 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$324.00 |