| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
277 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
78 |
$8K |
| D0274 |
Bitewings - four radiographic images |
321 |
317 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
74 |
$6K |
| D1120 |
Prophylaxis - child |
218 |
217 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
604 |
334 |
$5K |
| D1110 |
Prophylaxis - adult |
125 |
121 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
396 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
262 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
32 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
30 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
102 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
44 |
$888.99 |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$541.97 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$328.95 |