| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
980 |
466 |
$62K |
| D1110 |
Prophylaxis - adult |
1,248 |
1,248 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,201 |
1,200 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
623 |
618 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
184 |
$13K |
| D0274 |
Bitewings - four radiographic images |
442 |
442 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
183 |
79 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
111 |
$7K |
| D0330 |
Panoramic radiographic image |
214 |
214 |
$7K |
| D1206 |
Topical application of fluoride varnish |
362 |
362 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
711 |
704 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$4K |
| D1120 |
Prophylaxis - child |
112 |
112 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
55 |
$587.28 |
| D0270 |
|
27 |
27 |
$217.20 |