| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
757 |
751 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
531 |
519 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
434 |
167 |
$16K |
| D1120 |
Prophylaxis - child |
471 |
465 |
$11K |
| D1351 |
Sealant - per tooth |
1,175 |
168 |
$10K |
| D1206 |
Topical application of fluoride varnish |
465 |
459 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,356 |
536 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
611 |
599 |
$7K |
| D0274 |
Bitewings - four radiographic images |
248 |
242 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
233 |
75 |
$5K |
| D0272 |
Bitewings - two radiographic images |
270 |
268 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
311 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
186 |
77 |
$4K |
| D0240 |
|
155 |
153 |
$2K |
| D7311 |
|
69 |
39 |
$2K |
| D4355 |
|
60 |
60 |
$2K |
| D2140 |
|
141 |
42 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
311 |
$1K |
| D1110 |
Prophylaxis - adult |
118 |
117 |
$460.00 |
| D9110 |
|
35 |
34 |
$340.00 |
| D0602 |
|
58 |
58 |
$260.00 |
| D0601 |
|
17 |
16 |
$60.00 |
| D0120 |
Periodic oral evaluation - established patient |
139 |
137 |
$0.00 |
| D2160 |
|
29 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
12 |
$0.00 |