| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
407 |
326 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
404 |
350 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
27 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
400 |
363 |
$7K |
| D1120 |
Prophylaxis - child |
218 |
194 |
$6K |
| D1206 |
Topical application of fluoride varnish |
408 |
350 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
27 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
110 |
94 |
$3K |
| D1351 |
Sealant - per tooth |
64 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
24 |
$825.00 |