| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
20 |
$2K |
| D1110 |
Prophylaxis - adult |
48 |
47 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
50 |
$813.75 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$701.53 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$604.50 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
22 |
$570.90 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
72 |
$527.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
20 |
$482.47 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$481.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$249.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
23 |
$192.60 |