| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
117 |
$16K |
| D1110 |
Prophylaxis - adult |
369 |
369 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
127 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
431 |
431 |
$9K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
60 |
$4K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
175 |
$3K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
262 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
118 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$975.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$600.00 |