| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
242 |
228 |
$245.00 |
| D0191 |
|
200 |
200 |
$234.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
247 |
$228.00 |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
148 |
$174.00 |
| D0120 |
Periodic oral evaluation - established patient |
214 |
207 |
$168.00 |
| D0274 |
Bitewings - four radiographic images |
216 |
210 |
$145.00 |
| D0220 |
Intraoral - periapical first radiographic image |
308 |
295 |
$117.00 |
| D1206 |
Topical application of fluoride varnish |
266 |
261 |
$95.00 |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$94.00 |
| D1120 |
Prophylaxis - child |
157 |
153 |
$80.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
41 |
$71.00 |
| D9995 |
|
202 |
201 |
$65.00 |
| D0603 |
|
74 |
72 |
$33.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
44 |
$0.00 |
| D1310 |
|
492 |
492 |
$0.00 |
| D1330 |
|
623 |
616 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$0.00 |
| D0602 |
|
16 |
16 |
$0.00 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$0.00 |
| D4341 |
|
19 |
12 |
$0.00 |