| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,362 |
678 |
$124K |
| D0330 |
Panoramic radiographic image |
1,324 |
1,277 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,176 |
1,130 |
$27K |
| D1110 |
Prophylaxis - adult |
647 |
628 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
211 |
97 |
$11K |
| D0274 |
Bitewings - four radiographic images |
245 |
240 |
$5K |
| D2160 |
|
20 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
77 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D2140 |
|
21 |
13 |
$840.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
57 |
$810.00 |
| D0272 |
Bitewings - two radiographic images |
39 |
38 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
71 |
$275.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$240.00 |