| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
387 |
116 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$6K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
231 |
$4K |
| D1206 |
Topical application of fluoride varnish |
275 |
275 |
$4K |
| D1110 |
Prophylaxis - adult |
147 |
146 |
$3K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
42 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
131 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$500.00 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
93 |
$405.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$110.00 |