| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
328 |
123 |
$17K |
| D1110 |
Prophylaxis - adult |
496 |
494 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
737 |
736 |
$12K |
| D0274 |
Bitewings - four radiographic images |
520 |
518 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
337 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
75 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
146 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
143 |
51 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
63 |
$5K |
| D1206 |
Topical application of fluoride varnish |
293 |
292 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
305 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
229 |
229 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
472 |
$2K |
| D1120 |
Prophylaxis - child |
114 |
112 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$519.34 |
| D0350 |
|
73 |
73 |
$307.75 |
| D0701 |
|
28 |
28 |
$0.00 |