| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
51 |
51 |
$832.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$798.00 |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$551.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
148 |
75 |
$423.00 |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
92 |
$325.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
18 |
$280.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$175.00 |
| D0603 |
|
66 |
66 |
$165.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
14 |
$142.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$57.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$56.00 |
| D0602 |
|
12 |
12 |
$55.00 |
| D1310 |
|
106 |
106 |
$10.00 |
| D1330 |
|
107 |
107 |
$0.00 |