| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
786 |
731 |
$23K |
| D1206 |
Topical application of fluoride varnish |
561 |
523 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
364 |
215 |
$20K |
| D0274 |
Bitewings - four radiographic images |
929 |
875 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,321 |
1,081 |
$18K |
| D1120 |
Prophylaxis - child |
399 |
373 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,068 |
994 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
168 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
321 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
380 |
354 |
$8K |
| D0330 |
Panoramic radiographic image |
167 |
153 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
98 |
$5K |
| D2950 |
|
83 |
53 |
$4K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
30 |
13 |
$3K |
| D4346 |
|
120 |
93 |
$3K |
| D4341 |
|
82 |
20 |
$3K |
| D1351 |
Sealant - per tooth |
134 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
30 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$825.16 |
| D5899 |
|
52 |
44 |
$492.00 |
| D1110 |
Prophylaxis - adult |
14 |
12 |
$249.81 |