| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$175.00 |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$168.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$152.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$152.00 |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
112 |
$117.00 |
| D1120 |
Prophylaxis - child |
42 |
42 |
$80.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$58.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
40 |
$54.00 |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$47.00 |
| D0603 |
|
60 |
60 |
$44.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D1330 |
|
235 |
234 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |