| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
68 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
212 |
$6K |
| D1110 |
Prophylaxis - adult |
90 |
90 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
232 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D1206 |
Topical application of fluoride varnish |
60 |
60 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$960.70 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$809.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
46 |
$398.79 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$365.88 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$221.33 |