| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
548 |
301 |
$36K |
| D1110 |
Prophylaxis - adult |
650 |
644 |
$24K |
| D0274 |
Bitewings - four radiographic images |
654 |
647 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
660 |
654 |
$17K |
| D1351 |
Sealant - per tooth |
631 |
104 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
421 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
103 |
$11K |
| D1120 |
Prophylaxis - child |
306 |
304 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
512 |
509 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
855 |
839 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
805 |
708 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
140 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
40 |
$3K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$2K |
| D1999 |
|
274 |
257 |
$0.00 |