| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,373 |
565 |
$69K |
| D1110 |
Prophylaxis - adult |
1,258 |
1,248 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
528 |
411 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,178 |
1,173 |
$32K |
| D1120 |
Prophylaxis - child |
789 |
789 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
772 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,049 |
1,047 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
298 |
$21K |
| D0330 |
Panoramic radiographic image |
367 |
363 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
547 |
530 |
$17K |
| D0274 |
Bitewings - four radiographic images |
458 |
455 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
226 |
222 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
106 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
708 |
690 |
$9K |
| D0272 |
Bitewings - two radiographic images |
310 |
310 |
$8K |
| D1351 |
Sealant - per tooth |
111 |
37 |
$3K |
| D2331 |
|
39 |
29 |
$3K |
| D2330 |
|
36 |
28 |
$2K |
| D4910 |
|
46 |
45 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
117 |
$846.30 |