| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
357 |
354 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
115 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
422 |
$21K |
| D1110 |
Prophylaxis - adult |
257 |
255 |
$17K |
| D1351 |
Sealant - per tooth |
233 |
58 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
46 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
67 |
27 |
$8K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
40 |
$6K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$5K |
| D1206 |
Topical application of fluoride varnish |
175 |
175 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
41 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
12 |
$688.10 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$648.45 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
30 |
$324.39 |