| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
850 |
401 |
$100K |
| D1110 |
Prophylaxis - adult |
857 |
847 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,633 |
1,610 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,246 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,371 |
1,346 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,512 |
1,486 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
708 |
679 |
$32K |
| D0330 |
Panoramic radiographic image |
490 |
485 |
$22K |
| D1120 |
Prophylaxis - child |
464 |
456 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
346 |
340 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
72 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
724 |
$8K |
| D4355 |
|
70 |
68 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
228 |
219 |
$2K |
| D1330 |
|
302 |
302 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$1K |