| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,113 |
685 |
$79K |
| D1120 |
Prophylaxis - child |
1,256 |
1,256 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,528 |
1,527 |
$43K |
| D1110 |
Prophylaxis - adult |
784 |
784 |
$37K |
| D1351 |
Sealant - per tooth |
488 |
194 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,148 |
1,148 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,268 |
1,267 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
940 |
940 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
934 |
903 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,595 |
2,540 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
268 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,979 |
1,963 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
180 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
73 |
67 |
$6K |
| D2330 |
|
65 |
38 |
$4K |
| D0272 |
Bitewings - two radiographic images |
259 |
259 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
128 |
$3K |
| D2940 |
|
117 |
109 |
$1K |
| D0270 |
|
33 |
33 |
$184.80 |