| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
818 |
314 |
$79K |
| D0330 |
Panoramic radiographic image |
611 |
431 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
620 |
$20K |
| D1110 |
Prophylaxis - adult |
417 |
399 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
132 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
25 |
18 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
614 |
474 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
279 |
$9K |
| D0274 |
Bitewings - four radiographic images |
354 |
338 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
671 |
510 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
49 |
$6K |
| D2950 |
|
54 |
46 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
122 |
122 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
32 |
$413.66 |