| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,257 |
471 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
514 |
232 |
$26K |
| D1110 |
Prophylaxis - adult |
526 |
523 |
$16K |
| D0330 |
Panoramic radiographic image |
266 |
266 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
147 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
551 |
$9K |
| D0274 |
Bitewings - four radiographic images |
466 |
466 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
347 |
345 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
226 |
220 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
252 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
757 |
527 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
668 |
666 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
59 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$480.00 |
| D0350 |
|
39 |
39 |
$443.16 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$375.00 |