| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
561 |
489 |
$15K |
| D1120 |
Prophylaxis - child |
456 |
368 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
259 |
$14K |
| D1206 |
Topical application of fluoride varnish |
355 |
349 |
$11K |
| D0274 |
Bitewings - four radiographic images |
445 |
402 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
231 |
93 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,332 |
566 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
824 |
641 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
69 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
105 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
218 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
215 |
$4K |
| D2140 |
|
189 |
39 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
60 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
49 |
$2K |
| D9110 |
|
55 |
51 |
$1K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$895.66 |
| D0330 |
Panoramic radiographic image |
22 |
18 |
$618.60 |
| D5899 |
|
24 |
12 |
$287.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
12 |
$92.16 |
| D0601 |
|
14 |
14 |
$45.00 |