| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
34 |
34 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
71 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
56 |
$560.31 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$471.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
17 |
$275.19 |