| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
705 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
483 |
475 |
$14K |
| D1110 |
Prophylaxis - adult |
662 |
652 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
238 |
$6K |
| D2750 |
|
14 |
13 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
59 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
140 |
$3K |
| D1120 |
Prophylaxis - child |
142 |
139 |
$3K |
| D0274 |
Bitewings - four radiographic images |
299 |
292 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
483 |
474 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
609 |
280 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
120 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$750.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$715.00 |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$495.00 |
| D1330 |
|
940 |
921 |
$0.00 |