| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
925 |
307 |
$63K |
| D1110 |
Prophylaxis - adult |
1,535 |
1,533 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
807 |
532 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,661 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
548 |
385 |
$29K |
| D0274 |
Bitewings - four radiographic images |
905 |
900 |
$27K |
| D1351 |
Sealant - per tooth |
847 |
173 |
$22K |
| D1120 |
Prophylaxis - child |
560 |
557 |
$18K |
| D1206 |
Topical application of fluoride varnish |
919 |
911 |
$18K |
| D0330 |
Panoramic radiographic image |
361 |
358 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
499 |
495 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
163 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
127 |
84 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
464 |
454 |
$4K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$908.48 |