| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,382 |
323 |
$146K |
| D0140 |
Limited oral evaluation - problem focused |
2,975 |
2,908 |
$99K |
| D0330 |
Panoramic radiographic image |
876 |
866 |
$57K |
| D5110 |
|
85 |
83 |
$56K |
| D7250 |
|
206 |
40 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,175 |
1,087 |
$10K |
| D5130 |
|
13 |
13 |
$9K |
| D2950 |
|
63 |
50 |
$9K |
| D5120 |
|
17 |
14 |
$9K |
| D5140 |
|
13 |
13 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
67 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
27 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$4K |
| D1206 |
Topical application of fluoride varnish |
217 |
216 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
185 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
88 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$798.33 |
| D1110 |
Prophylaxis - adult |
14 |
12 |
$480.00 |