| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,187 |
935 |
$35K |
| D1120 |
Prophylaxis - child |
924 |
822 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
165 |
100 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
88 |
$16K |
| D1206 |
Topical application of fluoride varnish |
571 |
536 |
$12K |
| D0274 |
Bitewings - four radiographic images |
357 |
351 |
$8K |
| D0330 |
Panoramic radiographic image |
191 |
182 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
131 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
253 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
80 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
29 |
$895.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$217.79 |