| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$7K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
325 |
$6K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$5K |
| D1120 |
Prophylaxis - child |
150 |
150 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
385 |
380 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
438 |
324 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
133 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
78 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
53 |
52 |
$1K |