| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
534 |
147 |
$32K |
| D1110 |
Prophylaxis - adult |
553 |
548 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
668 |
665 |
$13K |
| D0330 |
Panoramic radiographic image |
334 |
327 |
$12K |
| D1120 |
Prophylaxis - child |
320 |
320 |
$10K |
| D1351 |
Sealant - per tooth |
383 |
61 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
432 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
69 |
$6K |
| D5110 |
|
14 |
14 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
271 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
55 |
$5K |
| D0274 |
Bitewings - four radiographic images |
164 |
163 |
$5K |
| D0272 |
Bitewings - two radiographic images |
223 |
222 |
$4K |
| D2332 |
|
48 |
30 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$2K |
| D2330 |
|
26 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
91 |
$684.00 |