| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
30 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
126 |
$2K |
| D0330 |
Panoramic radiographic image |
19 |
18 |
$969.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
15 |
$674.26 |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$546.42 |
| D1330 |
|
63 |
59 |
$151.00 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
33 |
$4.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
15 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
36 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$0.00 |