| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
381 |
380 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
26 |
$5K |
| D0272 |
Bitewings - two radiographic images |
468 |
467 |
$5K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$2K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
297 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
72 |
$300.00 |