| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
904 |
266 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
326 |
$34K |
| D1110 |
Prophylaxis - adult |
963 |
956 |
$33K |
| D0274 |
Bitewings - four radiographic images |
969 |
961 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,078 |
1,070 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
186 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
709 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
662 |
637 |
$5K |
| D4910 |
|
86 |
85 |
$5K |
| D0603 |
|
834 |
831 |
$4K |
| D0330 |
Panoramic radiographic image |
171 |
171 |
$4K |
| D2331 |
|
58 |
31 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
129 |
126 |
$3K |
| D4341 |
|
37 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D0601 |
|
250 |
250 |
$1K |
| D2330 |
|
13 |
12 |
$574.09 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$307.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
40 |
$286.30 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$254.70 |