| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
902 |
434 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,043 |
554 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
840 |
545 |
$44K |
| D1351 |
Sealant - per tooth |
1,719 |
348 |
$41K |
| D1110 |
Prophylaxis - adult |
1,010 |
1,008 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
708 |
706 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
465 |
289 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,194 |
1,192 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,251 |
1,222 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,057 |
1,055 |
$21K |
| D5110 |
|
39 |
39 |
$21K |
| D1120 |
Prophylaxis - child |
569 |
569 |
$18K |
| D1330 |
|
1,558 |
1,553 |
$18K |
| D1310 |
|
1,578 |
1,573 |
$18K |
| D0330 |
Panoramic radiographic image |
441 |
441 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
677 |
$11K |
| D2331 |
|
167 |
120 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
211 |
202 |
$10K |
| D5120 |
|
18 |
18 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
16 |
12 |
$9K |
| D0274 |
Bitewings - four radiographic images |
302 |
302 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
923 |
912 |
$7K |
| D2332 |
|
57 |
36 |
$4K |
| D0272 |
Bitewings - two radiographic images |
178 |
178 |
$3K |
| D2330 |
|
49 |
39 |
$2K |
| D9110 |
|
14 |
13 |
$358.04 |