| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
404 |
154 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
129 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
118 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
158 |
$6K |
| D1110 |
Prophylaxis - adult |
187 |
174 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
221 |
$6K |
| D0330 |
Panoramic radiographic image |
115 |
109 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
50 |
$4K |
| D2330 |
|
46 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
105 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
111 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
86 |
85 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$1K |
| D1206 |
Topical application of fluoride varnish |
86 |
86 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
226 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
162 |
$1K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$167.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$120.00 |