| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
70 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
186 |
98 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
89 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
139 |
77 |
$17K |
| D0330 |
Panoramic radiographic image |
99 |
97 |
$8K |
| D2331 |
|
58 |
28 |
$7K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
187 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
123 |
$6K |
| D0274 |
Bitewings - four radiographic images |
147 |
146 |
$5K |
| D2332 |
|
17 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
160 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$514.80 |