| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
476 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
79 |
$10K |
| D0330 |
Panoramic radiographic image |
173 |
172 |
$7K |
| D1110 |
Prophylaxis - adult |
209 |
205 |
$6K |
| D0274 |
Bitewings - four radiographic images |
289 |
285 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
43 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
563 |
334 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
187 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
373 |
362 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
63 |
$930.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$768.15 |
| D1120 |
Prophylaxis - child |
39 |
38 |
$740.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$248.38 |