| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
578 |
312 |
$38K |
| D1110 |
Prophylaxis - adult |
999 |
999 |
$36K |
| D0274 |
Bitewings - four radiographic images |
712 |
712 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
320 |
231 |
$18K |
| D1351 |
Sealant - per tooth |
716 |
102 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
650 |
649 |
$13K |
| D0330 |
Panoramic radiographic image |
337 |
336 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
453 |
$9K |
| D1120 |
Prophylaxis - child |
202 |
201 |
$6K |
| D2140 |
|
129 |
97 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
231 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
521 |
514 |
$4K |
| D2160 |
|
51 |
44 |
$3K |
| D1206 |
Topical application of fluoride varnish |
137 |
137 |
$3K |
| D2332 |
|
31 |
25 |
$2K |
| D2331 |
|
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
91 |
90 |
$1K |
| D9110 |
|
38 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
103 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$704.76 |
| D1330 |
|
14 |
13 |
$110.80 |
| D1310 |
|
14 |
13 |
$108.70 |