| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
725 |
260 |
$32K |
| D1110 |
Prophylaxis - adult |
745 |
724 |
$20K |
| D0274 |
Bitewings - four radiographic images |
971 |
951 |
$16K |
| D0330 |
Panoramic radiographic image |
413 |
394 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
981 |
954 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
471 |
454 |
$10K |
| D2394 |
|
164 |
86 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
292 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
807 |
774 |
$3K |
| D1120 |
Prophylaxis - child |
174 |
161 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
74 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
30 |
$3K |
| D7230 |
|
21 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
443 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
53 |
$919.78 |
| D0272 |
Bitewings - two radiographic images |
104 |
89 |
$800.00 |
| D1320 |
|
30 |
30 |
$450.00 |