| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,369 |
521 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
1,949 |
1,747 |
$2K |
| D5120 |
|
148 |
134 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,613 |
2,278 |
$2K |
| D5110 |
|
221 |
209 |
$1K |
| D1120 |
Prophylaxis - child |
1,697 |
1,546 |
$1K |
| D1206 |
Topical application of fluoride varnish |
5,207 |
4,809 |
$782.25 |
| D0220 |
Intraoral - periapical first radiographic image |
2,578 |
2,315 |
$712.26 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
292 |
$419.40 |
| D9996 |
|
883 |
668 |
$379.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
262 |
$370.45 |
| D1354 |
|
6,930 |
1,297 |
$368.42 |
| D1110 |
Prophylaxis - adult |
1,225 |
1,110 |
$364.29 |
| D0120 |
Periodic oral evaluation - established patient |
811 |
716 |
$300.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,182 |
879 |
$234.00 |
| D2394 |
|
87 |
56 |
$193.35 |
| D0272 |
Bitewings - two radiographic images |
365 |
329 |
$144.12 |
| D0274 |
Bitewings - four radiographic images |
901 |
796 |
$144.00 |
| D4341 |
|
79 |
39 |
$126.34 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
36 |
$113.42 |
| D1351 |
Sealant - per tooth |
1,262 |
274 |
$106.20 |
| D0210 |
Intraoral - complete series of radiographic images |
624 |
580 |
$100.83 |
| D2940 |
|
209 |
135 |
$88.14 |
| D0191 |
|
2,671 |
2,555 |
$48.01 |
| D0240 |
|
183 |
88 |
$48.00 |
| D5410 |
|
692 |
628 |
$37.10 |
| D1320 |
|
210 |
180 |
$33.60 |
| D0707 |
|
1,281 |
364 |
$31.20 |
| D0270 |
|
53 |
53 |
$30.80 |
| D9995 |
|
18 |
18 |
$29.00 |
| D0708 |
|
788 |
339 |
$16.50 |
| D1330 |
|
5,693 |
5,174 |
$0.00 |
| D0603 |
|
6,354 |
5,497 |
$0.00 |
| D0709 |
|
81 |
78 |
$0.00 |
| D1310 |
|
5,439 |
4,944 |
$0.00 |
| D0602 |
|
880 |
794 |
$0.00 |
| D0601 |
|
248 |
224 |
$0.00 |
| D5751 |
|
14 |
12 |
$0.00 |
| D0703 |
|
4,296 |
730 |
$0.00 |
| D1355 |
|
682 |
133 |
$0.00 |
| D0170 |
|
15 |
15 |
$0.00 |
| D5750 |
|
88 |
85 |
$0.00 |
| D5851 |
|
77 |
77 |
$0.00 |
| D2330 |
|
25 |
15 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
12 |
$0.00 |
| D0391 |
|
3,876 |
595 |
$0.00 |
| D5411 |
|
555 |
505 |
$0.00 |
| D5422 |
|
61 |
54 |
$0.00 |
| D5850 |
|
211 |
199 |
$0.00 |
| D0350 |
|
96 |
92 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
27 |
$0.00 |
| D4910 |
|
24 |
24 |
$0.00 |