| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
690 |
244 |
$45K |
| D1110 |
Prophylaxis - adult |
831 |
831 |
$30K |
| D0330 |
Panoramic radiographic image |
436 |
435 |
$16K |
| D0274 |
Bitewings - four radiographic images |
562 |
562 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
656 |
653 |
$13K |
| D1351 |
Sealant - per tooth |
263 |
44 |
$7K |
| D9110 |
|
219 |
216 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
119 |
72 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
287 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
614 |
610 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
237 |
$4K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$4K |
| D2332 |
|
56 |
42 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
40 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
42 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
184 |
$2K |
| D2140 |
|
42 |
30 |
$2K |
| D2335 |
|
24 |
15 |
$2K |
| D2331 |
|
21 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$950.00 |