| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
168 |
165 |
$150.00 |
| D1110 |
Prophylaxis - adult |
173 |
172 |
$127.50 |
| D1206 |
Topical application of fluoride varnish |
239 |
237 |
$75.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
197 |
$60.00 |
| D0220 |
Intraoral - periapical first radiographic image |
360 |
249 |
$0.00 |
| D9430 |
|
123 |
120 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
91 |
90 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |
| D0270 |
|
25 |
25 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
161 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
40 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
159 |
155 |
$0.00 |