| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
742 |
709 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
110 |
$15K |
| D0330 |
Panoramic radiographic image |
535 |
489 |
$12K |
| D1110 |
Prophylaxis - adult |
224 |
217 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
236 |
231 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
83 |
$7K |
| D1206 |
Topical application of fluoride varnish |
382 |
361 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
72 |
$6K |
| D1120 |
Prophylaxis - child |
192 |
178 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
264 |
214 |
$4K |
| D1351 |
Sealant - per tooth |
141 |
29 |
$3K |
| D0274 |
Bitewings - four radiographic images |
122 |
119 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
116 |
$1K |
| D1354 |
|
135 |
41 |
$1K |
| D2332 |
|
14 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
41 |
$581.91 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$256.10 |
| D0272 |
Bitewings - two radiographic images |
16 |
15 |
$220.86 |
| D1330 |
|
65 |
61 |
$0.00 |