| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
806 |
791 |
$477.90 |
| D1110 |
Prophylaxis - adult |
363 |
362 |
$471.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,199 |
1,129 |
$265.42 |
| D0120 |
Periodic oral evaluation - established patient |
462 |
459 |
$241.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,025 |
983 |
$214.61 |
| D1120 |
Prophylaxis - child |
423 |
422 |
$207.78 |
| D1206 |
Topical application of fluoride varnish |
356 |
353 |
$165.11 |
| D0330 |
Panoramic radiographic image |
501 |
493 |
$154.73 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
305 |
$150.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
287 |
287 |
$120.08 |
| D0140 |
Limited oral evaluation - problem focused |
241 |
234 |
$115.48 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
39 |
$0.00 |