| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
39 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
20 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$4K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
91 |
91 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D1206 |
Topical application of fluoride varnish |
107 |
107 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D0180 |
|
31 |
31 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$1K |
| D4910 |
|
19 |
19 |
$1K |
| D4346 |
|
25 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$726.60 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$673.06 |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$592.06 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$558.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
18 |
$266.42 |