| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
804 |
633 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,600 |
1,598 |
$9K |
| D0330 |
Panoramic radiographic image |
472 |
469 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,101 |
1,096 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
450 |
450 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
392 |
324 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
82 |
$2K |
| D0603 |
|
1,070 |
1,069 |
$2K |
| D1206 |
Topical application of fluoride varnish |
973 |
967 |
$2K |
| D1110 |
Prophylaxis - adult |
307 |
306 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
772 |
766 |
$1K |
| D1120 |
Prophylaxis - child |
506 |
506 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
83 |
$960.00 |
| D0140 |
Limited oral evaluation - problem focused |
558 |
550 |
$875.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
351 |
183 |
$585.00 |
| D1351 |
Sealant - per tooth |
343 |
84 |
$560.00 |
| D0191 |
|
263 |
262 |
$198.00 |
| D1354 |
|
235 |
61 |
$188.00 |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$180.00 |
| D0602 |
|
304 |
301 |
$143.00 |
| D0120 |
Periodic oral evaluation - established patient |
301 |
300 |
$140.00 |
| D1320 |
|
14 |
14 |
$60.00 |
| D0601 |
|
126 |
126 |
$55.00 |
| D9995 |
|
226 |
225 |
$51.00 |
| D0270 |
|
134 |
133 |
$22.00 |
| D1330 |
|
2,143 |
2,131 |
$10.00 |
| D1310 |
|
2,085 |
2,078 |
$0.00 |