| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
287 |
58 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
50 |
$7K |
| D1120 |
Prophylaxis - child |
277 |
267 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
299 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
166 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
300 |
$4K |
| D0330 |
Panoramic radiographic image |
84 |
82 |
$4K |
| D0274 |
Bitewings - four radiographic images |
193 |
187 |
$4K |
| D1110 |
Prophylaxis - adult |
110 |
106 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
149 |
$3K |
| D0272 |
Bitewings - two radiographic images |
178 |
172 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
321 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
213 |
$1K |