| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
459 |
121 |
$29K |
| D0330 |
Panoramic radiographic image |
554 |
550 |
$20K |
| D0274 |
Bitewings - four radiographic images |
656 |
643 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
840 |
828 |
$16K |
| D1110 |
Prophylaxis - adult |
386 |
382 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
91 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
63 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
244 |
239 |
$5K |
| D1206 |
Topical application of fluoride varnish |
184 |
183 |
$3K |
| D1120 |
Prophylaxis - child |
94 |
94 |
$3K |
| D1351 |
Sealant - per tooth |
103 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
327 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
40 |
$304.00 |