| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
408 |
397 |
$560.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
110 |
$497.00 |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$364.00 |
| D0220 |
Intraoral - periapical first radiographic image |
542 |
532 |
$325.00 |
| D1206 |
Topical application of fluoride varnish |
348 |
347 |
$323.00 |
| D1120 |
Prophylaxis - child |
121 |
121 |
$280.00 |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$235.00 |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$145.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
86 |
$114.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
262 |
$72.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$58.00 |
| D0270 |
|
64 |
63 |
$55.00 |
| D1310 |
|
17 |
17 |
$0.00 |
| D1330 |
|
17 |
17 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
75 |
73 |
$0.00 |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
45 |
$0.00 |