| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
122 |
119 |
$8K |
| D1120 |
Prophylaxis - child |
188 |
188 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$7K |
| D1351 |
Sealant - per tooth |
191 |
35 |
$6K |
| D1206 |
Topical application of fluoride varnish |
249 |
248 |
$5K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$5K |
| D1110 |
Prophylaxis - adult |
76 |
75 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
24 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$770.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
13 |
$231.00 |