| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
344 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
258 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
163 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
255 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
58 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
53 |
$6K |
| D1110 |
Prophylaxis - adult |
104 |
103 |
$4K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
42 |
$2K |
| D1206 |
Topical application of fluoride varnish |
276 |
276 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$197.29 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$0.00 |