| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
419 |
214 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
380 |
$12K |
| D1110 |
Prophylaxis - adult |
767 |
632 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
539 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
123 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
507 |
419 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
741 |
591 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
80 |
$3K |
| D0274 |
Bitewings - four radiographic images |
545 |
432 |
$2K |
| D1120 |
Prophylaxis - child |
216 |
169 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
398 |
$2K |
| D0330 |
Panoramic radiographic image |
116 |
109 |
$1K |
| D0601 |
|
446 |
394 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$762.00 |
| D0603 |
|
171 |
162 |
$688.00 |
| D0270 |
|
76 |
64 |
$228.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$91.00 |
| D1354 |
|
127 |
58 |
$79.00 |
| D0602 |
|
15 |
15 |
$61.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$19.00 |
| D1330 |
|
35 |
19 |
$0.00 |
| D1351 |
Sealant - per tooth |
16 |
12 |
$0.00 |