| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
360 |
161 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
186 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
123 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
349 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
67 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
322 |
$5K |
| D1120 |
Prophylaxis - child |
269 |
266 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
56 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
187 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
283 |
$4K |
| D1110 |
Prophylaxis - adult |
115 |
115 |
$4K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
195 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$483.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
16 |
$288.75 |
| D1999 |
|
61 |
58 |
$0.00 |