| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
853 |
397 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
679 |
452 |
$90K |
| D1110 |
Prophylaxis - adult |
873 |
852 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,289 |
1,249 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,664 |
2,547 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
887 |
868 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
537 |
518 |
$24K |
| D0330 |
Panoramic radiographic image |
531 |
513 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
351 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
829 |
807 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
118 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,773 |
1,725 |
$14K |
| D2332 |
|
40 |
25 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$6K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D2950 |
|
15 |
13 |
$1K |
| D1330 |
|
45 |
45 |
$270.00 |