| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
77 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
233 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
45 |
$5K |
| D1110 |
Prophylaxis - adult |
156 |
145 |
$4K |
| D1120 |
Prophylaxis - child |
166 |
160 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
37 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
390 |
$3K |
| D0274 |
Bitewings - four radiographic images |
173 |
163 |
$3K |
| D1206 |
Topical application of fluoride varnish |
205 |
192 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
447 |
329 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
127 |
$2K |
| D0272 |
Bitewings - two radiographic images |
124 |
120 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
55 |
$1K |
| D0330 |
Panoramic radiographic image |
35 |
32 |
$1K |
| D1330 |
|
37 |
37 |
$0.00 |
| D1310 |
|
22 |
22 |
$0.00 |