| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
238 |
238 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
332 |
331 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
65 |
$684.00 |
| D1206 |
Topical application of fluoride varnish |
200 |
199 |
$255.00 |
| D1351 |
Sealant - per tooth |
50 |
12 |
$243.00 |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$242.00 |
| D1120 |
Prophylaxis - child |
79 |
79 |
$110.00 |
| D0330 |
Panoramic radiographic image |
323 |
322 |
$37.75 |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
145 |
$24.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
82 |
$3.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
27 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
42 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |