| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,450 |
684 |
$114K |
| D1120 |
Prophylaxis - child |
2,524 |
2,524 |
$83K |
| D1110 |
Prophylaxis - adult |
1,715 |
1,696 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
3,673 |
3,667 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,488 |
3,488 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,169 |
909 |
$28K |
| D0330 |
Panoramic radiographic image |
791 |
517 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
220 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,043 |
1,037 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
187 |
$15K |
| D9630 |
|
748 |
735 |
$14K |
| D0274 |
Bitewings - four radiographic images |
453 |
453 |
$11K |
| D3120 |
|
393 |
295 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
493 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
200 |
150 |
$4K |
| D4910 |
|
54 |
54 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
24 |
$972.78 |