| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
101 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
224 |
$6K |
| D1110 |
Prophylaxis - adult |
157 |
157 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
81 |
$4K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$4K |
| D1206 |
Topical application of fluoride varnish |
261 |
260 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
49 |
$3K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
160 |
159 |
$3K |
| D1351 |
Sealant - per tooth |
114 |
30 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$1K |
| D1354 |
|
97 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$525.00 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
78 |
$425.25 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$304.50 |
| D1310 |
|
29 |
22 |
$0.00 |