| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
839 |
834 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
471 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
166 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
132 |
$7K |
| D1120 |
Prophylaxis - child |
444 |
444 |
$2K |
| D1110 |
Prophylaxis - adult |
136 |
133 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
26 |
$1K |
| D4355 |
|
12 |
12 |
$652.35 |
| D1206 |
Topical application of fluoride varnish |
428 |
428 |
$391.41 |
| D0601 |
|
385 |
380 |
$130.47 |
| D0330 |
Panoramic radiographic image |
199 |
194 |
$71.58 |
| D0274 |
Bitewings - four radiographic images |
181 |
180 |
$19.94 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
100 |
$0.00 |
| D0602 |
|
64 |
63 |
$0.00 |