| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
215 |
$988.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
65 |
$852.00 |
| D1110 |
Prophylaxis - adult |
143 |
140 |
$799.00 |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
460 |
$598.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
233 |
$532.00 |
| D0274 |
Bitewings - four radiographic images |
211 |
209 |
$464.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
476 |
336 |
$396.00 |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$112.00 |
| D0140 |
Limited oral evaluation - problem focused |
87 |
85 |
$105.00 |
| D1120 |
Prophylaxis - child |
27 |
27 |
$80.00 |
| D9986 |
|
176 |
171 |
$0.00 |
| D1330 |
|
207 |
206 |
$0.00 |
| D1310 |
|
159 |
159 |
$0.00 |