| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,437 |
700 |
$164K |
| D1110 |
Prophylaxis - adult |
2,842 |
2,769 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
4,126 |
4,057 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,622 |
4,547 |
$95K |
| D0330 |
Panoramic radiographic image |
2,100 |
2,056 |
$87K |
| D1120 |
Prophylaxis - child |
2,456 |
2,429 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,291 |
1,254 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,983 |
1,953 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,794 |
2,724 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,249 |
1,226 |
$32K |
| D9110 |
|
412 |
402 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,019 |
1,827 |
$19K |
| D1351 |
Sealant - per tooth |
559 |
185 |
$16K |
| D5110 |
|
15 |
15 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
127 |
$9K |
| D9248 |
|
34 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
40 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$246.00 |