| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
102 |
$416.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$350.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
65 |
$180.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$174.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$71.00 |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$57.00 |
| D4921 |
|
58 |
24 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$0.00 |
| D1330 |
|
15 |
14 |
$0.00 |