| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$569.80 |
| D0120 |
Periodic oral evaluation - established patient |
120 |
120 |
$230.03 |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
197 |
$203.83 |
| D9630 |
|
236 |
227 |
$129.15 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$88.37 |
| D9920 |
|
16 |
16 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
63 |
$0.00 |
| D3120 |
|
71 |
37 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
83 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$0.00 |
| D9310 |
|
13 |
13 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
46 |
$0.00 |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$0.00 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
51 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
20 |
13 |
$0.00 |