| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
956 |
284 |
$35K |
| D1110 |
Prophylaxis - adult |
649 |
594 |
$15K |
| D0330 |
Panoramic radiographic image |
324 |
301 |
$10K |
| D1206 |
Topical application of fluoride varnish |
813 |
748 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
486 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
362 |
338 |
$5K |
| D0274 |
Bitewings - four radiographic images |
375 |
339 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
562 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
866 |
328 |
$4K |
| D0272 |
Bitewings - two radiographic images |
233 |
218 |
$3K |
| D1120 |
Prophylaxis - child |
95 |
93 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
70 |
$700.07 |
| D1330 |
|
86 |
86 |
$653.71 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$0.00 |
| D2140 |
|
36 |
12 |
$0.00 |