| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
713 |
138 |
$42K |
| D1110 |
Prophylaxis - adult |
320 |
317 |
$10K |
| D0330 |
Panoramic radiographic image |
267 |
265 |
$9K |
| D0274 |
Bitewings - four radiographic images |
299 |
296 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
75 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
308 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
56 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
211 |
$4K |
| D1351 |
Sealant - per tooth |
91 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
105 |
105 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
194 |
$1K |
| D9110 |
|
45 |
42 |
$1K |
| D1310 |
|
62 |
61 |
$561.44 |
| D1330 |
|
59 |
58 |
$537.58 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$480.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$123.72 |