| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
994 |
562 |
$35K |
| D0330 |
Panoramic radiographic image |
706 |
703 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
640 |
632 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$6K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$5K |
| D0274 |
Bitewings - four radiographic images |
182 |
182 |
$4K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
34 |
$3K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
226 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$589.18 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$550.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$101.76 |