| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
283 |
115 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
335 |
$6K |
| D1110 |
Prophylaxis - adult |
149 |
148 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
65 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
185 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
265 |
$4K |
| D1120 |
Prophylaxis - child |
198 |
197 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
87 |
$2K |
| D0274 |
Bitewings - four radiographic images |
122 |
120 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
161 |
$887.25 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$645.24 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$136.50 |