| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
662 |
163 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
175 |
$10K |
| D1110 |
Prophylaxis - adult |
264 |
262 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
328 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
361 |
345 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
406 |
395 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
117 |
72 |
$7K |
| D1120 |
Prophylaxis - child |
272 |
267 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
327 |
323 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
47 |
$3K |
| D0274 |
Bitewings - four radiographic images |
155 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
287 |
$2K |
| D2160 |
|
16 |
14 |
$1K |
| D2331 |
|
14 |
13 |
$863.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
54 |
$637.25 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$484.08 |