| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
480 |
389 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
739 |
720 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
813 |
794 |
$1K |
| D1110 |
Prophylaxis - adult |
1,009 |
985 |
$1K |
| D1120 |
Prophylaxis - child |
478 |
461 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
275 |
274 |
$788.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,770 |
1,721 |
$729.00 |
| D0120 |
Periodic oral evaluation - established patient |
999 |
979 |
$728.00 |
| D1206 |
Topical application of fluoride varnish |
1,326 |
1,287 |
$722.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
128 |
$434.00 |
| D0274 |
Bitewings - four radiographic images |
727 |
709 |
$377.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,368 |
1,103 |
$234.00 |
| D0191 |
|
267 |
264 |
$108.00 |
| D0270 |
|
96 |
95 |
$77.00 |
| D0603 |
|
187 |
175 |
$77.00 |
| D0272 |
Bitewings - two radiographic images |
160 |
153 |
$60.00 |
| D9995 |
|
243 |
240 |
$25.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D1330 |
|
2,318 |
2,245 |
$0.00 |
| D1310 |
|
932 |
896 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
15 |
$0.00 |