| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
358 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
428 |
407 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
399 |
358 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
260 |
132 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
259 |
110 |
$10K |
| D1110 |
Prophylaxis - adult |
575 |
544 |
$5K |
| D2160 |
|
65 |
38 |
$5K |
| D2140 |
|
39 |
25 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,031 |
949 |
$2K |
| D0330 |
Panoramic radiographic image |
344 |
326 |
$1K |
| D0274 |
Bitewings - four radiographic images |
694 |
657 |
$865.98 |
| D1120 |
Prophylaxis - child |
137 |
133 |
$388.14 |
| D4355 |
|
74 |
74 |
$291.03 |
| D1206 |
Topical application of fluoride varnish |
167 |
156 |
$106.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
490 |
455 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |