| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
152 |
$38.00 |
| D0274 |
Bitewings - four radiographic images |
126 |
124 |
$29.00 |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
254 |
$13.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
121 |
$9.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
48 |
$0.00 |
| D1110 |
Prophylaxis - adult |
152 |
151 |
$0.00 |
| D0270 |
|
13 |
13 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$0.00 |
| D1330 |
|
199 |
194 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$0.00 |
| D1310 |
|
48 |
48 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
230 |
226 |
$0.00 |
| D0603 |
|
14 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$0.00 |