| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
373 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
816 |
803 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
364 |
$2K |
| D0274 |
Bitewings - four radiographic images |
402 |
402 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
935 |
586 |
$1K |
| D1120 |
Prophylaxis - child |
177 |
177 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
219 |
$722.00 |
| D0120 |
Periodic oral evaluation - established patient |
254 |
254 |
$644.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
57 |
$639.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
42 |
$320.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
32 |
$280.00 |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$235.00 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$220.00 |
| D0270 |
|
84 |
84 |
$187.00 |
| D1310 |
|
106 |
106 |
$0.00 |
| D1330 |
|
250 |
249 |
$0.00 |
| D9986 |
|
311 |
298 |
$0.00 |