| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$76.00 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$58.00 |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$35.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$29.00 |
| D0601 |
|
16 |
16 |
$11.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
23 |
$9.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$0.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$0.00 |
| D1330 |
|
74 |
72 |
$0.00 |
| D0603 |
|
27 |
27 |
$0.00 |
| D1310 |
|
72 |
70 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$0.00 |