| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,006 |
1,004 |
$2K |
| D1110 |
Prophylaxis - adult |
1,431 |
1,426 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
444 |
443 |
$2K |
| D1206 |
Topical application of fluoride varnish |
2,220 |
2,212 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
850 |
830 |
$1K |
| D2394 |
|
354 |
186 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
1,645 |
1,643 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,260 |
2,159 |
$961.08 |
| D0274 |
Bitewings - four radiographic images |
1,199 |
1,195 |
$754.00 |
| D4341 |
|
107 |
37 |
$722.80 |
| D4910 |
|
578 |
578 |
$563.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
53 |
$504.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,468 |
1,381 |
$315.00 |
| D0602 |
|
781 |
763 |
$140.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
12 |
$110.00 |
| D0601 |
|
708 |
679 |
$90.00 |
| D0603 |
|
33 |
29 |
$50.00 |
| D1999 |
|
27 |
26 |
$49.00 |
| D2335 |
|
91 |
36 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
38 |
$0.00 |
| D4921 |
|
146 |
51 |
$0.00 |
| D0330 |
Panoramic radiographic image |
89 |
88 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |