| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,235 |
555 |
$104K |
| D1110 |
Prophylaxis - adult |
885 |
885 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
250 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
678 |
674 |
$26K |
| D0330 |
Panoramic radiographic image |
497 |
497 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
862 |
862 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
470 |
470 |
$19K |
| D0274 |
Bitewings - four radiographic images |
648 |
648 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
136 |
108 |
$14K |
| D1120 |
Prophylaxis - child |
337 |
337 |
$12K |
| D1206 |
Topical application of fluoride varnish |
607 |
607 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
104 |
$9K |
| D0272 |
Bitewings - two radiographic images |
314 |
314 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$2K |
| D2331 |
|
20 |
12 |
$2K |
| D2330 |
|
12 |
12 |
$747.74 |