| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
431 |
153 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
167 |
$14K |
| D1110 |
Prophylaxis - adult |
417 |
401 |
$10K |
| D0274 |
Bitewings - four radiographic images |
585 |
564 |
$9K |
| D1120 |
Prophylaxis - child |
433 |
430 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
466 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,163 |
1,087 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
566 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
115 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
599 |
593 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,402 |
932 |
$6K |
| D0272 |
Bitewings - two radiographic images |
262 |
259 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
156 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$683.52 |