| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
491 |
489 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
313 |
$11K |
| D0330 |
Panoramic radiographic image |
449 |
446 |
$11K |
| D1110 |
Prophylaxis - adult |
352 |
348 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
116 |
41 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
391 |
$555.89 |
| D1208 |
Topical application of fluoride, excluding varnish |
393 |
388 |
$430.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
379 |
376 |
$71.17 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$70.02 |
| D1330 |
|
407 |
401 |
$48.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |