| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
292 |
97 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
83 |
$21K |
| D4342 |
|
215 |
61 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
252 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
166 |
$5K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$4K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
279 |
$3K |
| D2950 |
|
16 |
15 |
$2K |
| D4910 |
|
28 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
114 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
14 |
$167.40 |