| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
177 |
$988.00 |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
119 |
$812.00 |
| D1110 |
Prophylaxis - adult |
369 |
356 |
$564.00 |
| D1120 |
Prophylaxis - child |
256 |
252 |
$520.00 |
| D0140 |
Limited oral evaluation - problem focused |
171 |
168 |
$385.00 |
| D0274 |
Bitewings - four radiographic images |
352 |
339 |
$348.00 |
| D1206 |
Topical application of fluoride varnish |
436 |
423 |
$323.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
66 |
$284.00 |
| D0120 |
Periodic oral evaluation - established patient |
399 |
387 |
$224.00 |
| D0602 |
|
393 |
383 |
$165.00 |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
162 |
$143.00 |
| D2940 |
|
15 |
12 |
$105.00 |
| D0330 |
Panoramic radiographic image |
98 |
94 |
$104.00 |
| D0603 |
|
285 |
275 |
$55.00 |
| D1330 |
|
764 |
740 |
$50.00 |
| D0270 |
|
13 |
13 |
$22.00 |
| D1310 |
|
60 |
58 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |
| D4910 |
|
34 |
32 |
$0.00 |
| D0350 |
|
246 |
147 |
$0.00 |
| D0191 |
|
23 |
19 |
$0.00 |
| D9996 |
|
23 |
20 |
$0.00 |