| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
145 |
130 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
70 |
$6K |
| D1110 |
Prophylaxis - adult |
92 |
83 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
121 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
92 |
86 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
70 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$957.61 |
| D1120 |
Prophylaxis - child |
31 |
30 |
$617.00 |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
70 |
$353.50 |