| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
610 |
268 |
$39K |
| D1110 |
Prophylaxis - adult |
742 |
731 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,229 |
1,212 |
$24K |
| D1351 |
Sealant - per tooth |
940 |
143 |
$23K |
| D0330 |
Panoramic radiographic image |
479 |
472 |
$17K |
| D0274 |
Bitewings - four radiographic images |
587 |
575 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
173 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
158 |
$12K |
| D1120 |
Prophylaxis - child |
304 |
301 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
425 |
$8K |
| D2330 |
|
138 |
73 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
84 |
$6K |
| D2332 |
|
92 |
60 |
$6K |
| D0272 |
Bitewings - two radiographic images |
210 |
207 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
333 |
$2K |
| D2331 |
|
27 |
22 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D1999 |
|
15 |
14 |
$91.00 |