| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
221 |
$17K |
| D0274 |
Bitewings - four radiographic images |
241 |
234 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
27 |
$4K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
70 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
96 |
$872.85 |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$350.24 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$141.45 |