| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
69 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
111 |
$2K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$886.35 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$819.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
76 |
$747.01 |
| D0601 |
|
118 |
110 |
$0.00 |