| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
110 |
109 |
$280.00 |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
346 |
$143.00 |
| D0120 |
Periodic oral evaluation - established patient |
86 |
85 |
$84.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
89 |
$76.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
72 |
$45.00 |
| D0270 |
|
29 |
28 |
$11.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
82 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
90 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$0.00 |
| D0603 |
|
80 |
80 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$0.00 |
| D9986 |
|
49 |
48 |
$0.00 |