| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
328 |
176 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
141 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
412 |
$12K |
| D1110 |
Prophylaxis - adult |
281 |
278 |
$9K |
| D0274 |
Bitewings - four radiographic images |
444 |
443 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
348 |
347 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,151 |
451 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
115 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
48 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
732 |
722 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
120 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$956.40 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$435.00 |