| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
91 |
91 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
187 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
179 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
149 |
149 |
$2K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$790.50 |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
127 |
$635.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$480.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$240.00 |