| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
878 |
410 |
$56K |
| D1110 |
Prophylaxis - adult |
1,515 |
1,511 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
743 |
519 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
2,133 |
2,123 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
579 |
407 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,008 |
1,006 |
$28K |
| D0330 |
Panoramic radiographic image |
453 |
452 |
$17K |
| D1120 |
Prophylaxis - child |
508 |
503 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
801 |
793 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
44 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$3K |
| D2330 |
|
41 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$782.00 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
57 |
$451.35 |