| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
45 |
$16K |
| D1351 |
Sealant - per tooth |
250 |
47 |
$9K |
| D0330 |
Panoramic radiographic image |
201 |
177 |
$6K |
| D1110 |
Prophylaxis - adult |
189 |
172 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
263 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
46 |
$5K |
| D0274 |
Bitewings - four radiographic images |
161 |
143 |
$4K |
| D1206 |
Topical application of fluoride varnish |
160 |
138 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
92 |
77 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
95 |
$2K |
| D1330 |
|
169 |
160 |
$1K |
| D1310 |
|
172 |
163 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
40 |
$307.19 |