| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
791 |
479 |
$44K |
| D1110 |
Prophylaxis - adult |
987 |
987 |
$34K |
| D1351 |
Sealant - per tooth |
1,301 |
243 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,088 |
1,088 |
$21K |
| D0274 |
Bitewings - four radiographic images |
763 |
761 |
$20K |
| D1120 |
Prophylaxis - child |
657 |
657 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
801 |
801 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
924 |
924 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
229 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,177 |
1,159 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,041 |
845 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
52 |
$5K |
| D0272 |
Bitewings - two radiographic images |
286 |
286 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
57 |
$987.20 |