| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
775 |
774 |
$39K |
| D1330 |
|
367 |
367 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
401 |
401 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
60 |
$4K |
| D1110 |
Prophylaxis - adult |
251 |
251 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
32 |
$2K |
| D1351 |
Sealant - per tooth |
66 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D1999 |
|
21 |
21 |
$840.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
13 |
$597.75 |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$597.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
368 |
$520.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
741 |
412 |
$445.05 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$382.09 |
| D1120 |
Prophylaxis - child |
95 |
95 |
$156.25 |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
452 |
$123.68 |
| D0330 |
Panoramic radiographic image |
284 |
284 |
$92.00 |