| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
228 |
$3K |
| D0274 |
Bitewings - four radiographic images |
235 |
235 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
121 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
389 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
83 |
$1K |
| D1120 |
Prophylaxis - child |
115 |
114 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
506 |
308 |
$1K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
125 |
$875.00 |
| D1206 |
Topical application of fluoride varnish |
187 |
186 |
$684.00 |
| D0120 |
Periodic oral evaluation - established patient |
158 |
158 |
$672.00 |
| D2331 |
|
46 |
31 |
$576.00 |
| D2332 |
|
18 |
14 |
$495.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$200.00 |
| D4910 |
|
12 |
12 |
$70.00 |
| D1330 |
|
399 |
394 |
$0.04 |
| D9986 |
|
138 |
136 |
$0.00 |