| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
35 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
57 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
58 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
38 |
$8K |
| D2331 |
|
49 |
25 |
$6K |
| D1110 |
Prophylaxis - adult |
77 |
76 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
162 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
97 |
$4K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$3K |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
56 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
77 |
$753.91 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$157.20 |