| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
558 |
251 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
784 |
766 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
580 |
566 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
275 |
176 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
151 |
$30K |
| D1110 |
Prophylaxis - adult |
331 |
320 |
$21K |
| D1206 |
Topical application of fluoride varnish |
628 |
607 |
$15K |
| D0330 |
Panoramic radiographic image |
278 |
274 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
397 |
387 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
56 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
796 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
137 |
$8K |
| D0274 |
Bitewings - four radiographic images |
287 |
280 |
$7K |
| D1120 |
Prophylaxis - child |
137 |
137 |
$6K |
| D3110 |
|
162 |
111 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
13 |
$2K |
| D3120 |
|
24 |
13 |
$840.00 |
| D1330 |
|
43 |
43 |
$258.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$195.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$118.08 |
| D0270 |
|
13 |
13 |
$117.00 |