| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
1,713 |
1,713 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
964 |
514 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,859 |
1,859 |
$71K |
| D0140 |
Limited oral evaluation - problem focused |
1,853 |
1,847 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,627 |
1,627 |
$43K |
| D1110 |
Prophylaxis - adult |
833 |
833 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
337 |
185 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
221 |
145 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,691 |
1,680 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
164 |
164 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
362 |
359 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
138 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$194.40 |