| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
162 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
108 |
$2K |
| D1206 |
Topical application of fluoride varnish |
557 |
555 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
136 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
117 |
$2K |
| D1110 |
Prophylaxis - adult |
237 |
235 |
$2K |
| D1120 |
Prophylaxis - child |
156 |
156 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
414 |
405 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
349 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
575 |
254 |
$1K |
| D4910 |
|
129 |
129 |
$1K |
| D0274 |
Bitewings - four radiographic images |
184 |
183 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
58 |
$952.00 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$754.00 |
| D4341 |
|
24 |
13 |
$180.00 |
| D0240 |
|
23 |
12 |
$160.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$100.00 |
| D1310 |
|
66 |
66 |
$0.01 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
28 |
$0.00 |