| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,146 |
367 |
$57K |
| D1110 |
Prophylaxis - adult |
1,247 |
1,192 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,365 |
1,302 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
217 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
754 |
710 |
$19K |
| D0330 |
Panoramic radiographic image |
441 |
421 |
$19K |
| D0274 |
Bitewings - four radiographic images |
951 |
896 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
764 |
721 |
$11K |
| D1120 |
Prophylaxis - child |
582 |
544 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
101 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
418 |
392 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,079 |
516 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,075 |
949 |
$5K |
| D1351 |
Sealant - per tooth |
197 |
32 |
$4K |
| D0272 |
Bitewings - two radiographic images |
160 |
153 |
$2K |
| D2331 |
|
17 |
12 |
$952.35 |