| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
127 |
127 |
$517.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$380.00 |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
77 |
$304.00 |
| D1206 |
Topical application of fluoride varnish |
202 |
200 |
$266.00 |
| D0274 |
Bitewings - four radiographic images |
121 |
119 |
$232.00 |
| D0120 |
Periodic oral evaluation - established patient |
112 |
112 |
$224.00 |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
170 |
$169.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
16 |
$142.00 |
| D4910 |
|
42 |
42 |
$140.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
141 |
$81.00 |
| D4921 |
|
236 |
88 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
30 |
$0.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |