| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,512 |
214 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
743 |
403 |
$81K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
421 |
257 |
$63K |
| D1110 |
Prophylaxis - adult |
456 |
456 |
$19K |
| D0330 |
Panoramic radiographic image |
383 |
383 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,302 |
1,227 |
$18K |
| D5130 |
|
20 |
20 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
513 |
$15K |
| D5140 |
|
17 |
17 |
$14K |
| D0274 |
Bitewings - four radiographic images |
469 |
469 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,640 |
967 |
$12K |
| D2394 |
|
46 |
27 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$7K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$750.24 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$399.31 |