| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
927 |
293 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,800 |
1,761 |
$33K |
| D1110 |
Prophylaxis - adult |
1,328 |
1,315 |
$32K |
| D1206 |
Topical application of fluoride varnish |
2,191 |
2,160 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
628 |
361 |
$25K |
| D0330 |
Panoramic radiographic image |
682 |
662 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,615 |
1,598 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,016 |
1,804 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
732 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
671 |
646 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,191 |
1,210 |
$11K |
| D1120 |
Prophylaxis - child |
561 |
557 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
160 |
$7K |
| D4355 |
|
216 |
216 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
119 |
74 |
$4K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$3K |
| D1330 |
|
280 |
279 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
26 |
16 |
$1K |
| D2331 |
|
43 |
32 |
$754.92 |
| D1351 |
Sealant - per tooth |
147 |
17 |
$88.92 |