| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
434 |
403 |
$25K |
| D1110 |
Prophylaxis - adult |
424 |
400 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
517 |
479 |
$17K |
| D0274 |
Bitewings - four radiographic images |
187 |
184 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
36 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
127 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
33 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
348 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
141 |
$1K |
| D1206 |
Topical application of fluoride varnish |
63 |
58 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$844.56 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$268.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$201.00 |