| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
308 |
302 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
108 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
382 |
373 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
139 |
35 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
32 |
$4K |
| D1120 |
Prophylaxis - child |
147 |
146 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
105 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
15 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$1K |
| D1206 |
Topical application of fluoride varnish |
74 |
74 |
$1K |
| D1351 |
Sealant - per tooth |
50 |
14 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$819.12 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$260.00 |