| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
464 |
306 |
$27K |
| D1120 |
Prophylaxis - child |
425 |
413 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
706 |
671 |
$14K |
| D1110 |
Prophylaxis - adult |
293 |
285 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
397 |
372 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
417 |
$10K |
| D0274 |
Bitewings - four radiographic images |
656 |
622 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
64 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
838 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
488 |
437 |
$4K |
| D1351 |
Sealant - per tooth |
36 |
26 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
47 |
29 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
151 |
$3K |
| D0272 |
Bitewings - two radiographic images |
189 |
178 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$771.25 |
| D2140 |
|
18 |
12 |
$678.70 |
| D1999 |
|
75 |
62 |
$0.00 |