| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
334 |
147 |
$20K |
| D1206 |
Topical application of fluoride varnish |
967 |
953 |
$15K |
| D1110 |
Prophylaxis - adult |
405 |
400 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
716 |
706 |
$13K |
| D1120 |
Prophylaxis - child |
503 |
495 |
$10K |
| D0274 |
Bitewings - four radiographic images |
475 |
468 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
359 |
351 |
$8K |
| D0330 |
Panoramic radiographic image |
172 |
169 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
259 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
44 |
$4K |
| D0272 |
Bitewings - two radiographic images |
244 |
243 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
308 |
$2K |
| D2140 |
|
22 |
13 |
$924.00 |
| D1351 |
Sealant - per tooth |
37 |
12 |
$854.70 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$752.78 |
| D1320 |
|
44 |
43 |
$693.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
15 |
$267.75 |