| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
500 |
155 |
$17K |
| D0330 |
Panoramic radiographic image |
421 |
410 |
$13K |
| D2394 |
|
231 |
114 |
$13K |
| D1110 |
Prophylaxis - adult |
485 |
480 |
$13K |
| D0274 |
Bitewings - four radiographic images |
626 |
617 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
92 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
323 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
421 |
417 |
$6K |
| D2335 |
|
50 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
30 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
153 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
119 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
431 |
421 |
$2K |
| D1120 |
Prophylaxis - child |
83 |
82 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
329 |
$1K |
| D2332 |
|
17 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$563.31 |
| D1999 |
|
14 |
14 |
$0.00 |