| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
451 |
200 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
953 |
907 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,275 |
1,267 |
$39K |
| D1110 |
Prophylaxis - adult |
439 |
431 |
$23K |
| D1206 |
Topical application of fluoride varnish |
998 |
978 |
$18K |
| D1120 |
Prophylaxis - child |
467 |
452 |
$17K |
| D0274 |
Bitewings - four radiographic images |
288 |
280 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
444 |
433 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
816 |
775 |
$6K |
| D0330 |
Panoramic radiographic image |
105 |
102 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
51 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$624.00 |