| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
144 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
381 |
381 |
$15K |
| D1120 |
Prophylaxis - child |
392 |
392 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
69 |
$13K |
| D1206 |
Topical application of fluoride varnish |
501 |
501 |
$13K |
| D0272 |
Bitewings - two radiographic images |
288 |
288 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
114 |
$7K |
| D1351 |
Sealant - per tooth |
137 |
57 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
227 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$5K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$3K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$748.00 |