| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
778 |
778 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
464 |
463 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
557 |
549 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
619 |
587 |
$767.00 |
| D1206 |
Topical application of fluoride varnish |
280 |
280 |
$589.00 |
| D1120 |
Prophylaxis - child |
163 |
162 |
$495.00 |
| D0270 |
|
186 |
181 |
$220.00 |
| D0120 |
Periodic oral evaluation - established patient |
75 |
75 |
$196.00 |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$174.00 |
| D0603 |
|
92 |
92 |
$154.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
111 |
$135.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
49 |
$112.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
52 |
$71.00 |
| D0602 |
|
30 |
29 |
$66.00 |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$52.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$20.00 |
| D9995 |
|
113 |
113 |
$20.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D1330 |
|
586 |
584 |
$0.00 |
| D1310 |
|
555 |
555 |
$0.00 |