| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
336 |
187 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
289 |
$11K |
| D1110 |
Prophylaxis - adult |
205 |
201 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
318 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
171 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
103 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$776.10 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$735.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$593.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
29 |
$464.40 |