| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,959 |
652 |
$1K |
| D1120 |
Prophylaxis - child |
2,516 |
843 |
$928.08 |
| D0330 |
Panoramic radiographic image |
1,353 |
468 |
$547.26 |
| D0210 |
Intraoral - complete series of radiographic images |
249 |
67 |
$458.95 |
| D1206 |
Topical application of fluoride varnish |
2,275 |
760 |
$411.28 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
33 |
$340.29 |
| D0140 |
Limited oral evaluation - problem focused |
2,015 |
651 |
$322.20 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
21 |
$288.46 |
| D0274 |
Bitewings - four radiographic images |
360 |
104 |
$75.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
16 |
$73.41 |
| D0120 |
Periodic oral evaluation - established patient |
633 |
217 |
$34.31 |
| D0470 |
|
41 |
15 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
17 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
375 |
108 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
48 |
13 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
125 |
27 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
52 |
$0.00 |
| D0340 |
|
43 |
18 |
$0.00 |
| D0350 |
|
41 |
17 |
$0.00 |