| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
890 |
886 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,065 |
1,058 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
837 |
551 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,207 |
1,198 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,647 |
952 |
$16K |
| D1110 |
Prophylaxis - adult |
1,109 |
1,106 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
93 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
165 |
111 |
$6K |
| D1120 |
Prophylaxis - child |
387 |
382 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
108 |
$4K |
| D0330 |
Panoramic radiographic image |
184 |
184 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
349 |
341 |
$3K |
| D1206 |
Topical application of fluoride varnish |
984 |
977 |
$2K |
| D1330 |
|
1,733 |
1,725 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,234 |
1,220 |
$623.41 |
| D7111 |
|
20 |
12 |
$464.70 |
| D1351 |
Sealant - per tooth |
181 |
39 |
$454.00 |
| D0274 |
Bitewings - four radiographic images |
447 |
444 |
$264.00 |
| D9986 |
|
15 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
56 |
55 |
$0.00 |