| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
393 |
68 |
$25K |
| D1110 |
Prophylaxis - adult |
588 |
584 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
330 |
146 |
$17K |
| D0274 |
Bitewings - four radiographic images |
552 |
549 |
$14K |
| D0330 |
Panoramic radiographic image |
363 |
360 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
181 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
458 |
455 |
$9K |
| D2160 |
|
126 |
71 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
379 |
$7K |
| D1310 |
|
271 |
271 |
$3K |
| D1330 |
|
258 |
258 |
$3K |
| D1351 |
Sealant - per tooth |
90 |
17 |
$2K |
| D1206 |
Topical application of fluoride varnish |
113 |
112 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
261 |
$2K |
| D2332 |
|
27 |
15 |
$2K |
| D9110 |
|
55 |
53 |
$2K |
| D2140 |
|
24 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$960.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
55 |
$508.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$307.20 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$176.00 |