| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
171 |
38 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
27 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
40 |
$8K |
| D1320 |
|
193 |
193 |
$7K |
| D4341 |
|
36 |
16 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
698 |
259 |
$6K |
| D0274 |
Bitewings - four radiographic images |
180 |
180 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
342 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$5K |
| D1206 |
Topical application of fluoride varnish |
294 |
281 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
43 |
$4K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
46 |
$1K |
| D0350 |
|
39 |
39 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$951.28 |
| D4910 |
|
14 |
14 |
$803.82 |
| D0603 |
|
19 |
19 |
$173.85 |