| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
974 |
972 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
664 |
660 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
906 |
895 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,121 |
1,091 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
118 |
$859.00 |
| D1206 |
Topical application of fluoride varnish |
429 |
428 |
$703.00 |
| D0603 |
|
233 |
233 |
$407.00 |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$406.00 |
| D1120 |
Prophylaxis - child |
148 |
148 |
$394.00 |
| D0270 |
|
399 |
396 |
$341.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
275 |
$261.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
56 |
$224.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$60.00 |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$56.00 |
| D0602 |
|
28 |
28 |
$55.00 |
| D0330 |
Panoramic radiographic image |
80 |
79 |
$52.00 |
| D1110 |
Prophylaxis - adult |
25 |
24 |
$47.00 |
| D9995 |
|
120 |
120 |
$25.00 |
| D1330 |
|
859 |
854 |
$20.00 |
| D1320 |
|
15 |
15 |
$10.00 |
| D1310 |
|
782 |
780 |
$0.00 |