| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
2,071 |
1,639 |
$66K |
| D1120 |
Prophylaxis - child |
1,563 |
1,237 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,434 |
1,135 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
25 |
$15K |
| D0330 |
Panoramic radiographic image |
372 |
315 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
149 |
38 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
137 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
139 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
13 |
$650.44 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$250.32 |