| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,853 |
308 |
$116K |
| D1110 |
Prophylaxis - adult |
1,376 |
1,373 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,483 |
1,479 |
$37K |
| D0330 |
Panoramic radiographic image |
1,049 |
1,045 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
444 |
256 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,260 |
1,255 |
$24K |
| D1351 |
Sealant - per tooth |
878 |
112 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
181 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
977 |
977 |
$18K |
| D1330 |
|
892 |
892 |
$10K |
| D1310 |
|
894 |
894 |
$10K |
| D1206 |
Topical application of fluoride varnish |
489 |
489 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,237 |
1,210 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
531 |
$5K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$5K |
| D9110 |
|
128 |
123 |
$4K |
| D2332 |
|
49 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$672.68 |
| D1999 |
|
25 |
22 |
$0.00 |