| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
661 |
661 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
235 |
$23K |
| D0274 |
Bitewings - four radiographic images |
811 |
811 |
$22K |
| D1110 |
Prophylaxis - adult |
564 |
560 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
753 |
752 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
151 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
100 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
351 |
$7K |
| D9110 |
|
167 |
164 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
393 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
31 |
$3K |
| D1206 |
Topical application of fluoride varnish |
126 |
126 |
$2K |
| D1351 |
Sealant - per tooth |
87 |
19 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$2K |
| D1310 |
|
143 |
143 |
$2K |
| D1330 |
|
130 |
130 |
$2K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$489.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
15 |
$150.00 |