| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
612 |
605 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
130 |
$19K |
| D0274 |
Bitewings - four radiographic images |
235 |
232 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$3K |
| D1120 |
Prophylaxis - child |
460 |
459 |
$1K |
| D0272 |
Bitewings - two radiographic images |
153 |
152 |
$833.00 |
| D0140 |
Limited oral evaluation - problem focused |
130 |
125 |
$604.68 |
| D1206 |
Topical application of fluoride varnish |
423 |
420 |
$436.25 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
25 |
$273.87 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$100.48 |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
26 |
$0.00 |
| D2140 |
|
40 |
25 |
$0.00 |