| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
967 |
952 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
461 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,312 |
1,295 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
194 |
$2K |
| D1120 |
Prophylaxis - child |
301 |
301 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
131 |
$2K |
| D1206 |
Topical application of fluoride varnish |
576 |
574 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
42 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
515 |
515 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
832 |
712 |
$711.00 |
| D0270 |
|
337 |
334 |
$440.00 |
| D1110 |
Prophylaxis - adult |
350 |
349 |
$282.00 |
| D4355 |
|
27 |
27 |
$126.00 |
| D0274 |
Bitewings - four radiographic images |
344 |
344 |
$87.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
105 |
49 |
$80.00 |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$0.00 |
| D2940 |
|
17 |
13 |
$0.00 |
| D9986 |
|
21 |
21 |
$0.00 |
| D1330 |
|
844 |
837 |
$0.00 |
| D9995 |
|
117 |
115 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$0.00 |
| D1310 |
|
273 |
271 |
$0.00 |
| D0603 |
|
69 |
69 |
$0.00 |