| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,203 |
350 |
$73K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
116 |
57 |
$57K |
| D1110 |
Prophylaxis - adult |
1,357 |
1,354 |
$48K |
| D0330 |
Panoramic radiographic image |
1,212 |
1,210 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
675 |
325 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,514 |
1,511 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,949 |
1,947 |
$37K |
| D1351 |
Sealant - per tooth |
1,346 |
221 |
$33K |
| D5110 |
|
42 |
42 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
345 |
173 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
788 |
786 |
$16K |
| D1120 |
Prophylaxis - child |
461 |
461 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
707 |
$13K |
| D1330 |
|
858 |
857 |
$10K |
| D1310 |
|
858 |
857 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
64 |
$6K |
| D9110 |
|
196 |
195 |
$6K |
| D8670 |
Periodic orthodontic treatment visit |
56 |
56 |
$6K |
| D2332 |
|
82 |
33 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
942 |
934 |
$5K |
| D1206 |
Topical application of fluoride varnish |
184 |
184 |
$3K |
| D0272 |
Bitewings - two radiographic images |
181 |
181 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
351 |
315 |
$2K |
| D2331 |
|
20 |
12 |
$1K |