| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,671 |
433 |
$111K |
| D1206 |
Topical application of fluoride varnish |
3,279 |
3,208 |
$69K |
| D1110 |
Prophylaxis - adult |
1,411 |
1,377 |
$63K |
| D1354 |
|
3,804 |
813 |
$30K |
| D0330 |
Panoramic radiographic image |
545 |
535 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
717 |
699 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
524 |
511 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
400 |
$12K |
| D1120 |
Prophylaxis - child |
345 |
345 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
97 |
$10K |
| D0274 |
Bitewings - four radiographic images |
360 |
349 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
225 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$512.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$445.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
12 |
$155.96 |
| D0180 |
|
15 |
14 |
$0.00 |
| D1330 |
|
1,582 |
1,514 |
$0.00 |