| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
346 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
102 |
$3K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
153 |
$2K |
| D1206 |
Topical application of fluoride varnish |
62 |
62 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0180 |
|
27 |
27 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$536.90 |