| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,099 |
397 |
$183K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,777 |
791 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,026 |
1,860 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,503 |
1,388 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,274 |
1,186 |
$47K |
| D1110 |
Prophylaxis - adult |
1,050 |
966 |
$44K |
| D0330 |
Panoramic radiographic image |
822 |
748 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,783 |
2,488 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,194 |
1,118 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
368 |
209 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,741 |
1,942 |
$21K |
| D1120 |
Prophylaxis - child |
905 |
859 |
$21K |
| D1206 |
Topical application of fluoride varnish |
963 |
901 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
207 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
23 |
12 |
$10K |
| D2931 |
|
31 |
24 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
225 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
105 |
$3K |
| D1351 |
Sealant - per tooth |
57 |
16 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$354.78 |
| D9920 |
|
15 |
15 |
$233.75 |
| D9130 |
|
34 |
30 |
$0.00 |
| D1330 |
|
25 |
25 |
$0.00 |