| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
193 |
57 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
254 |
100 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
94 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
43 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
255 |
$13K |
| D0330 |
Panoramic radiographic image |
235 |
220 |
$11K |
| D1110 |
Prophylaxis - adult |
95 |
91 |
$5K |
| D0274 |
Bitewings - four radiographic images |
153 |
146 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
217 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
225 |
$3K |
| D1351 |
Sealant - per tooth |
87 |
12 |
$3K |
| D2331 |
|
15 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$576.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
20 |
$509.80 |