| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$836.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$280.00 |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$247.00 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$232.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
31 |
$224.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
17 |
$213.00 |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$203.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
64 |
$162.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$114.00 |
| D0603 |
|
38 |
38 |
$99.00 |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$84.00 |
| D1330 |
|
30 |
30 |
$0.00 |