| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
601 |
316 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
657 |
290 |
$39K |
| D1110 |
Prophylaxis - adult |
1,017 |
1,012 |
$36K |
| D1351 |
Sealant - per tooth |
1,146 |
199 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,104 |
1,097 |
$27K |
| D0274 |
Bitewings - four radiographic images |
920 |
915 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
520 |
$14K |
| D1120 |
Prophylaxis - child |
389 |
389 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
230 |
89 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
616 |
616 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
232 |
228 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,007 |
1,002 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
932 |
852 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
43 |
$4K |
| D0272 |
Bitewings - two radiographic images |
187 |
187 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$408.20 |
| D1999 |
|
361 |
329 |
$0.00 |