| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
203 |
80 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
86 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
58 |
$6K |
| D1110 |
Prophylaxis - adult |
118 |
117 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
169 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
100 |
$2K |
| D0274 |
Bitewings - four radiographic images |
126 |
122 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
29 |
$1K |
| D2394 |
|
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
235 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
62 |
$915.00 |
| D1120 |
Prophylaxis - child |
48 |
44 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
140 |
$815.00 |