| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
34 |
$6K |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$5K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
120 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
115 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
110 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D1120 |
Prophylaxis - child |
19 |
19 |
$636.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$249.48 |