| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
900 |
895 |
$51.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,028 |
920 |
$41.50 |
| D0220 |
Intraoral - periapical first radiographic image |
1,056 |
1,037 |
$25.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
410 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
124 |
124 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
128 |
122 |
$0.00 |
| D0330 |
Panoramic radiographic image |
186 |
186 |
$0.00 |
| D1110 |
Prophylaxis - adult |
608 |
602 |
$0.00 |
| D1120 |
Prophylaxis - child |
91 |
91 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$0.00 |