| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
371 |
371 |
$16K |
| D1110 |
Prophylaxis - adult |
450 |
450 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
151 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
68 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
28 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
788 |
787 |
$3K |
| D1120 |
Prophylaxis - child |
75 |
75 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
381 |
$1K |
| D0274 |
Bitewings - four radiographic images |
398 |
397 |
$912.00 |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
702 |
$641.00 |
| D1330 |
|
868 |
866 |
$463.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
590 |
$388.36 |