| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
405 |
379 |
$15K |
| D0330 |
Panoramic radiographic image |
245 |
237 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
260 |
$8K |
| D1110 |
Prophylaxis - adult |
251 |
239 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
25 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
181 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
528 |
499 |
$6K |
| D4355 |
|
73 |
64 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
30 |
$4K |
| D0274 |
Bitewings - four radiographic images |
262 |
259 |
$3K |
| D9110 |
|
32 |
28 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
357 |
$3K |
| D1206 |
Topical application of fluoride varnish |
112 |
112 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
66 |
$1K |
| D0191 |
|
114 |
101 |
$1K |