| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
65 |
$15K |
| D0330 |
Panoramic radiographic image |
141 |
140 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
54 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
180 |
$11K |
| D1120 |
Prophylaxis - child |
213 |
207 |
$10K |
| D0274 |
Bitewings - four radiographic images |
195 |
187 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
214 |
$9K |
| D1110 |
Prophylaxis - adult |
125 |
117 |
$8K |
| D1206 |
Topical application of fluoride varnish |
307 |
294 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
39 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
187 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
282 |
$7K |
| D1351 |
Sealant - per tooth |
164 |
39 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
88 |
$5K |
| D0272 |
Bitewings - two radiographic images |
108 |
103 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
31 |
$699.00 |