| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
104 |
97 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
121 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
128 |
$3K |
| D1110 |
Prophylaxis - adult |
82 |
81 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
19 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
251 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
26 |
$880.08 |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$760.00 |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
93 |
$435.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$100.00 |