| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$304.00 |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$188.00 |
| D1206 |
Topical application of fluoride varnish |
136 |
136 |
$133.00 |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
201 |
$117.00 |
| D0120 |
Periodic oral evaluation - established patient |
208 |
208 |
$112.00 |
| D1120 |
Prophylaxis - child |
54 |
54 |
$80.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
201 |
76 |
$54.00 |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$35.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
27 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$0.00 |