| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
919 |
898 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
575 |
562 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
1,176 |
1,120 |
$2K |
| D1110 |
Prophylaxis - adult |
1,129 |
1,112 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,642 |
2,559 |
$910.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
976 |
$756.00 |
| D0274 |
Bitewings - four radiographic images |
1,224 |
1,192 |
$667.00 |
| D1206 |
Topical application of fluoride varnish |
1,863 |
1,830 |
$644.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
184 |
$616.00 |
| D1120 |
Prophylaxis - child |
1,071 |
1,054 |
$600.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,298 |
1,814 |
$594.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
219 |
$497.00 |
| D1351 |
Sealant - per tooth |
145 |
65 |
$315.00 |
| D0603 |
|
744 |
730 |
$297.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
42 |
$240.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
13 |
$110.00 |
| D0270 |
|
288 |
271 |
$99.00 |
| D0272 |
Bitewings - two radiographic images |
138 |
138 |
$60.00 |
| D0330 |
Panoramic radiographic image |
107 |
102 |
$52.00 |
| D0601 |
|
37 |
37 |
$11.00 |
| D1310 |
|
2,194 |
2,133 |
$10.00 |
| D1330 |
|
3,079 |
2,942 |
$10.00 |
| D0190 |
|
205 |
205 |
$0.00 |
| D0191 |
|
105 |
105 |
$0.00 |
| D4341 |
|
24 |
13 |
$0.00 |
| D9995 |
|
73 |
73 |
$0.00 |
| D4355 |
|
12 |
12 |
$0.00 |
| D0602 |
|
33 |
33 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
37 |
37 |
$0.00 |