| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
383 |
216 |
$22K |
| D1110 |
Prophylaxis - adult |
574 |
571 |
$20K |
| D0274 |
Bitewings - four radiographic images |
356 |
352 |
$9K |
| D0330 |
Panoramic radiographic image |
314 |
313 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
93 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
402 |
400 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
196 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
54 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
237 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
101 |
$5K |
| D9110 |
|
133 |
131 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
486 |
$4K |
| D1330 |
|
523 |
520 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
359 |
289 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
27 |
$2K |
| D1206 |
Topical application of fluoride varnish |
71 |
71 |
$1K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$487.00 |