| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
3,206 |
883 |
$313K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,037 |
1,299 |
$277K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,596 |
929 |
$168K |
| D0330 |
Panoramic radiographic image |
2,159 |
2,159 |
$109K |
| D1110 |
Prophylaxis - adult |
2,463 |
2,458 |
$102K |
| D0274 |
Bitewings - four radiographic images |
2,580 |
2,580 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,890 |
1,889 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,677 |
2,676 |
$60K |
| D4342 |
|
592 |
272 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
343 |
246 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,579 |
1,572 |
$53K |
| D2740 |
Crown - porcelain/ceramic |
26 |
24 |
$12K |
| D1120 |
Prophylaxis - child |
205 |
205 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
290 |
$4K |
| D3910 |
|
32 |
12 |
$3K |
| D2331 |
|
22 |
13 |
$3K |
| D2950 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$1K |
| D4355 |
|
12 |
12 |
$960.72 |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$639.60 |