| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
286 |
284 |
$210.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
453 |
$76.00 |
| D1206 |
Topical application of fluoride varnish |
919 |
915 |
$76.00 |
| D0120 |
Periodic oral evaluation - established patient |
384 |
381 |
$56.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
594 |
545 |
$54.00 |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
650 |
$52.00 |
| D1110 |
Prophylaxis - adult |
316 |
315 |
$47.00 |
| D0140 |
Limited oral evaluation - problem focused |
185 |
175 |
$35.00 |
| D0274 |
Bitewings - four radiographic images |
411 |
408 |
$29.00 |
| D0602 |
|
202 |
197 |
$10.00 |
| D0603 |
|
160 |
157 |
$10.00 |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
40 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
30 |
$0.00 |
| D1330 |
|
29 |
29 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$0.00 |
| D4910 |
|
134 |
134 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D4921 |
|
32 |
13 |
$0.00 |