| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,912 |
898 |
$251K |
| D1110 |
Prophylaxis - adult |
2,324 |
2,323 |
$126K |
| D0210 |
Intraoral - complete series of radiographic images |
873 |
871 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
291 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
1,065 |
1,043 |
$48K |
| D5110 |
|
51 |
51 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
268 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,524 |
1,524 |
$40K |
| D1120 |
Prophylaxis - child |
892 |
892 |
$37K |
| D0274 |
Bitewings - four radiographic images |
988 |
988 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,076 |
1,075 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,401 |
1,371 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
463 |
$21K |
| D5120 |
|
14 |
14 |
$13K |
| D0272 |
Bitewings - two radiographic images |
204 |
204 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
442 |
293 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0191 |
|
100 |
100 |
$2K |
| D4355 |
|
13 |
13 |
$2K |