| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
540 |
254 |
$37K |
| D1120 |
Prophylaxis - child |
561 |
561 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
824 |
824 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
695 |
695 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
437 |
425 |
$11K |
| D1110 |
Prophylaxis - adult |
226 |
226 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
605 |
591 |
$7K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$5K |
| D0272 |
Bitewings - two radiographic images |
180 |
180 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
32 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
15 |
$872.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
37 |
$559.00 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$395.01 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$358.80 |