| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,003 |
255 |
$51K |
| D1110 |
Prophylaxis - adult |
1,482 |
1,467 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
863 |
416 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,420 |
1,404 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
307 |
174 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
729 |
718 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
307 |
295 |
$15K |
| D0274 |
Bitewings - four radiographic images |
591 |
581 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,001 |
1,040 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
581 |
$8K |
| D1120 |
Prophylaxis - child |
400 |
378 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,547 |
1,451 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
310 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
69 |
$5K |
| D1206 |
Topical application of fluoride varnish |
204 |
203 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
66 |
$3K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$946.00 |