| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
178 |
62 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
40 |
$8K |
| D1120 |
Prophylaxis - child |
118 |
117 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
141 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
148 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$843.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
32 |
$339.52 |