| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
3,157 |
209 |
$258K |
| D0999 |
Unspecified diagnostic procedure, by report |
829 |
767 |
$107K |
| D5130 |
|
153 |
147 |
$77K |
| D5140 |
|
146 |
136 |
$60K |
| D5110 |
|
123 |
119 |
$56K |
| D5120 |
|
64 |
61 |
$24K |
| D0330 |
Panoramic radiographic image |
598 |
473 |
$19K |
| D1110 |
Prophylaxis - adult |
768 |
624 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
488 |
397 |
$11K |
| D0274 |
Bitewings - four radiographic images |
434 |
358 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
88 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
735 |
623 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
686 |
523 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
171 |
$2K |
| D1351 |
Sealant - per tooth |
568 |
76 |
$1K |
| D1120 |
Prophylaxis - child |
652 |
520 |
$924.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
1,700 |
1,387 |
$629.73 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
54 |
$613.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
816 |
646 |
$572.00 |
| D0272 |
Bitewings - two radiographic images |
170 |
131 |
$247.50 |
| D1206 |
Topical application of fluoride varnish |
96 |
87 |
$198.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
16 |
$176.00 |