| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,605 |
632 |
$113K |
| D1110 |
Prophylaxis - adult |
1,377 |
1,270 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,566 |
1,426 |
$49K |
| D0274 |
Bitewings - four radiographic images |
955 |
867 |
$32K |
| D0330 |
Panoramic radiographic image |
582 |
548 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,160 |
1,078 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
432 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
95 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,345 |
1,119 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
52 |
$7K |
| D1206 |
Topical application of fluoride varnish |
141 |
124 |
$2K |
| D1120 |
Prophylaxis - child |
27 |
25 |
$483.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
12 |
$326.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$228.00 |