| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
272 |
271 |
$2K |
| D1110 |
Prophylaxis - adult |
533 |
533 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
257 |
$2K |
| D1120 |
Prophylaxis - child |
369 |
367 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
917 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
100 |
$1K |
| D1206 |
Topical application of fluoride varnish |
617 |
616 |
$912.00 |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
681 |
$871.00 |
| D0140 |
Limited oral evaluation - problem focused |
217 |
217 |
$735.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
57 |
$616.00 |
| D0274 |
Bitewings - four radiographic images |
529 |
528 |
$580.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
288 |
$396.00 |
| D0191 |
|
65 |
65 |
$108.00 |
| D0330 |
Panoramic radiographic image |
123 |
122 |
$104.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$20.00 |
| D1330 |
|
87 |
87 |
$0.00 |