| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
206 |
166 |
$5K |
| D1110 |
Prophylaxis - adult |
120 |
92 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
122 |
$3K |
| D0274 |
Bitewings - four radiographic images |
165 |
133 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
27 |
17 |
$476.19 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$404.25 |
| D0120 |
Periodic oral evaluation - established patient |
58 |
30 |
$387.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
28 |
$297.15 |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
78 |
$271.26 |