| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
999 |
345 |
$55K |
| D1110 |
Prophylaxis - adult |
370 |
354 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
360 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
168 |
102 |
$9K |
| D0330 |
Panoramic radiographic image |
192 |
181 |
$6K |
| D0274 |
Bitewings - four radiographic images |
426 |
405 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
293 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
165 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
465 |
429 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
612 |
201 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
24 |
$1K |
| D2160 |
|
17 |
13 |
$975.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
45 |
$675.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$520.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$110.00 |