| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
440 |
164 |
$18K |
| D1120 |
Prophylaxis - child |
421 |
418 |
$16K |
| D1351 |
Sealant - per tooth |
349 |
118 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
144 |
$12K |
| D1206 |
Topical application of fluoride varnish |
416 |
413 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
334 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
137 |
68 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
308 |
307 |
$6K |
| D0330 |
Panoramic radiographic image |
200 |
199 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
60 |
$4K |
| D0274 |
Bitewings - four radiographic images |
221 |
220 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
425 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
402 |
384 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
131 |
130 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
30 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$47.20 |