| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
90 |
90 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
57 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
44 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
47 |
$7K |
| D1206 |
Topical application of fluoride varnish |
211 |
211 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
120 |
$5K |
| D1351 |
Sealant - per tooth |
119 |
32 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
142 |
142 |
$5K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$4K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D1354 |
|
55 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
105 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$137.62 |