| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
104 |
104 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
203 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
44 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
88 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
45 |
$3K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D1206 |
Topical application of fluoride varnish |
108 |
107 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
32 |
$852.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$661.43 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
32 |
$300.75 |