| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
158 |
65 |
$9K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
268 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$5K |
| D0330 |
Panoramic radiographic image |
241 |
241 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
171 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
160 |
159 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
194 |
$4K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
300 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
225 |
$1K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$547.74 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$473.20 |