| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
222 |
222 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
196 |
87 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
42 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
219 |
213 |
$11K |
| D1206 |
Topical application of fluoride varnish |
333 |
333 |
$9K |
| D1120 |
Prophylaxis - child |
185 |
185 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$7K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$5K |
| D1351 |
Sealant - per tooth |
118 |
29 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
159 |
$4K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$3K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$3K |