| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
338 |
320 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
16 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
116 |
$4K |
| D1206 |
Topical application of fluoride varnish |
204 |
192 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
355 |
232 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
43 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
13 |
$457.35 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
16 |
$367.42 |