| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,249 |
402 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,150 |
494 |
$67K |
| D1110 |
Prophylaxis - adult |
1,260 |
1,255 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
495 |
308 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,115 |
1,112 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,243 |
$26K |
| D0330 |
Panoramic radiographic image |
674 |
671 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
439 |
224 |
$22K |
| D2332 |
|
320 |
149 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
674 |
670 |
$13K |
| D1351 |
Sealant - per tooth |
495 |
68 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
562 |
560 |
$10K |
| D1120 |
Prophylaxis - child |
305 |
305 |
$9K |
| D9110 |
|
210 |
206 |
$6K |
| D2330 |
|
121 |
55 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
416 |
$3K |
| D2331 |
|
19 |
12 |
$1K |
| D0270 |
|
55 |
54 |
$432.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$400.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$216.00 |