| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
290 |
255 |
$24K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
466 |
425 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
136 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
100 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$3K |
| D1120 |
Prophylaxis - child |
164 |
163 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
206 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
236 |
235 |
$2K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$2K |
| D0603 |
|
106 |
106 |
$930.00 |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
334 |
$868.50 |
| D1351 |
Sealant - per tooth |
82 |
30 |
$820.00 |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$630.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
162 |
$481.25 |
| D9910 |
|
29 |
29 |
$140.00 |
| 91301 |
|
14 |
14 |
$0.00 |
| D1330 |
|
32 |
29 |
$0.00 |
| D1999 |
|
20 |
12 |
$0.00 |