| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
412 |
186 |
$29K |
| D1110 |
Prophylaxis - adult |
457 |
447 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
830 |
782 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
573 |
550 |
$21K |
| D0274 |
Bitewings - four radiographic images |
376 |
371 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
457 |
$11K |
| D1120 |
Prophylaxis - child |
188 |
185 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
688 |
654 |
$6K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
66 |
36 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
55 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
130 |
129 |
$2K |
| D2140 |
|
42 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
55 |
$852.00 |