| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
173 |
$228.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$35.00 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$29.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$26.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$19.00 |
| D0603 |
|
53 |
53 |
$11.00 |
| D1330 |
|
185 |
184 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |
| D1310 |
|
191 |
189 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
13 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
15 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
17 |
$0.00 |