| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,262 |
506 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
971 |
957 |
$93K |
| D0140 |
Limited oral evaluation - problem focused |
744 |
686 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
754 |
746 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
539 |
406 |
$64K |
| D1110 |
Prophylaxis - adult |
857 |
849 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
169 |
$20K |
| D4355 |
|
140 |
139 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
139 |
120 |
$16K |
| D1120 |
Prophylaxis - child |
392 |
389 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
528 |
528 |
$13K |
| D1206 |
Topical application of fluoride varnish |
449 |
446 |
$11K |
| D0274 |
Bitewings - four radiographic images |
239 |
238 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
533 |
$3K |
| D0330 |
Panoramic radiographic image |
74 |
73 |
$598.68 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$240.00 |