| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
159 |
126 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
149 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
122 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
69 |
$974.20 |
| D0330 |
Panoramic radiographic image |
29 |
27 |
$877.83 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$624.75 |
| D0603 |
|
226 |
195 |
$0.00 |