| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
490 |
190 |
$33K |
| D1110 |
Prophylaxis - adult |
773 |
764 |
$28K |
| D0274 |
Bitewings - four radiographic images |
843 |
834 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
838 |
824 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
172 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
409 |
402 |
$17K |
| D1351 |
Sealant - per tooth |
584 |
89 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
654 |
$14K |
| D1120 |
Prophylaxis - child |
325 |
324 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
477 |
476 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,100 |
808 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
913 |
900 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
49 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
72 |
71 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$216.00 |
| D1999 |
|
876 |
809 |
$0.00 |