| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
253 |
84 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
91 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$6K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
227 |
227 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
35 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
36 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
100 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$741.12 |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
104 |
$520.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
68 |
$415.00 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$330.00 |