| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,763 |
1,754 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,085 |
2,037 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,039 |
3,131 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,114 |
1,103 |
$48K |
| D1120 |
Prophylaxis - child |
1,184 |
1,160 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,979 |
1,937 |
$36K |
| D0350 |
|
3,203 |
1,033 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
234 |
98 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,278 |
1,268 |
$15K |
| D9430 |
|
343 |
330 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
42 |
$5K |
| D1320 |
|
127 |
127 |
$2K |
| D1310 |
|
37 |
36 |
$2K |
| D9993 |
|
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
129 |
126 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$990.00 |
| D4910 |
|
14 |
12 |
$847.00 |
| D4341 |
|
31 |
13 |
$770.00 |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$550.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$96.00 |
| D1330 |
|
69 |
51 |
$0.00 |