| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,339 |
760 |
$20K |
| D1120 |
Prophylaxis - child |
1,394 |
782 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,804 |
1,006 |
$13K |
| D0274 |
Bitewings - four radiographic images |
978 |
536 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,910 |
1,065 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,633 |
913 |
$6K |
| D0272 |
Bitewings - two radiographic images |
551 |
321 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
460 |
245 |
$3K |
| D0330 |
Panoramic radiographic image |
183 |
117 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
79 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
85 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
12 |
$262.84 |