| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
479 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
478 |
467 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
42 |
$2K |
| D1110 |
Prophylaxis - adult |
266 |
266 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
487 |
487 |
$1K |
| D1120 |
Prophylaxis - child |
283 |
283 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
464 |
$842.38 |
| D1206 |
Topical application of fluoride varnish |
360 |
352 |
$684.00 |
| D0274 |
Bitewings - four radiographic images |
331 |
331 |
$580.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
31 |
$497.00 |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$416.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$20.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$9.00 |
| D1354 |
|
62 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$0.00 |