| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,447 |
523 |
$65K |
| D2740 |
Crown - porcelain/ceramic |
53 |
44 |
$20K |
| D0330 |
Panoramic radiographic image |
574 |
563 |
$20K |
| D1110 |
Prophylaxis - adult |
678 |
673 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
688 |
679 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
155 |
$10K |
| D0274 |
Bitewings - four radiographic images |
578 |
571 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
689 |
664 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
478 |
255 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
290 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
61 |
$3K |
| D5110 |
|
12 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$1K |
| D2331 |
|
20 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
271 |
120 |
$730.53 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$518.65 |
| D9986 |
|
14 |
14 |
$0.00 |