| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
239 |
67 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
99 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
79 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
69 |
$15K |
| D2331 |
|
93 |
41 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$10K |
| D1110 |
Prophylaxis - adult |
167 |
165 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
225 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
321 |
$8K |
| D0274 |
Bitewings - four radiographic images |
272 |
269 |
$7K |
| D0330 |
Panoramic radiographic image |
73 |
73 |
$6K |
| D2330 |
|
47 |
25 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
146 |
$4K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
164 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$196.50 |