| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
199 |
95 |
$11K |
| D1110 |
Prophylaxis - adult |
151 |
143 |
$7K |
| D1120 |
Prophylaxis - child |
153 |
145 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
200 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
188 |
176 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
62 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
109 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
121 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
49 |
$3K |
| D0274 |
Bitewings - four radiographic images |
124 |
116 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
202 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
106 |
$528.66 |
| D0270 |
|
70 |
63 |
$358.40 |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$166.35 |