| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
140 |
$18K |
| D0330 |
Panoramic radiographic image |
554 |
544 |
$17K |
| D0274 |
Bitewings - four radiographic images |
410 |
405 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
205 |
71 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
556 |
$11K |
| D1110 |
Prophylaxis - adult |
306 |
303 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
163 |
65 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
94 |
$9K |
| D1351 |
Sealant - per tooth |
201 |
38 |
$5K |
| D1206 |
Topical application of fluoride varnish |
280 |
273 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
251 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
67 |
$3K |
| D1120 |
Prophylaxis - child |
101 |
100 |
$3K |
| D1330 |
|
277 |
277 |
$3K |
| D1310 |
|
278 |
277 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
145 |
$1K |