| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
610 |
82 |
$48K |
| D0274 |
Bitewings - four radiographic images |
670 |
590 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,327 |
984 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,182 |
1,044 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
291 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
69 |
$6K |
| D1110 |
Prophylaxis - adult |
633 |
561 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
14 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
44 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
138 |
$2K |
| D1206 |
Topical application of fluoride varnish |
165 |
132 |
$971.02 |