| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,749 |
1,747 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
1,113 |
1,112 |
$21K |
| D1110 |
Prophylaxis - adult |
1,726 |
1,724 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
754 |
522 |
$13K |
| D1206 |
Topical application of fluoride varnish |
2,636 |
2,630 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
902 |
516 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
1,053 |
1,028 |
$9K |
| D2335 |
|
164 |
91 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,166 |
2,143 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,056 |
1,055 |
$5K |
| D4910 |
|
322 |
322 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
1,012 |
1,012 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,838 |
1,440 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
105 |
$3K |
| D1120 |
Prophylaxis - child |
393 |
393 |
$3K |
| D2332 |
|
80 |
52 |
$1K |
| D4342 |
|
51 |
27 |
$1K |
| D0603 |
|
390 |
389 |
$1K |
| D2330 |
|
36 |
26 |
$486.00 |
| D4341 |
|
25 |
14 |
$450.00 |
| D0601 |
|
110 |
110 |
$253.00 |
| D1351 |
Sealant - per tooth |
24 |
12 |
$140.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$20.00 |
| D1330 |
|
188 |
185 |
$20.00 |
| D0602 |
|
27 |
27 |
$11.00 |
| D9986 |
|
463 |
446 |
$0.00 |
| D1310 |
|
24 |
24 |
$0.00 |