| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
420 |
414 |
$986.00 |
| D0330 |
Panoramic radiographic image |
927 |
917 |
$676.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
452 |
447 |
$494.00 |
| D0274 |
Bitewings - four radiographic images |
836 |
828 |
$348.00 |
| D4341 |
|
515 |
335 |
$270.00 |
| D0140 |
Limited oral evaluation - problem focused |
201 |
195 |
$245.00 |
| D4342 |
|
370 |
236 |
$207.00 |
| D0180 |
|
482 |
475 |
$168.00 |
| D0603 |
|
904 |
891 |
$157.00 |
| D0220 |
Intraoral - periapical first radiographic image |
507 |
468 |
$117.00 |
| D1110 |
Prophylaxis - adult |
408 |
408 |
$94.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
73 |
$84.00 |
| D1206 |
Topical application of fluoride varnish |
445 |
445 |
$38.00 |
| D0270 |
|
15 |
15 |
$11.00 |
| D1320 |
|
102 |
101 |
$0.01 |
| D1330 |
|
2,031 |
1,687 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
220 |
128 |
$0.00 |
| D1310 |
|
936 |
921 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
101 |
57 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
456 |
362 |
$0.00 |
| D2331 |
|
37 |
25 |
$0.00 |
| D2330 |
|
16 |
13 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$0.00 |
| D9986 |
|
1,298 |
1,138 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
618 |
416 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$0.00 |
| D4910 |
|
28 |
28 |
$0.00 |