| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
619 |
112 |
$41K |
| D0330 |
Panoramic radiographic image |
777 |
759 |
$28K |
| D0274 |
Bitewings - four radiographic images |
770 |
758 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
155 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
774 |
$16K |
| D1110 |
Prophylaxis - adult |
418 |
413 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
485 |
479 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
17 |
15 |
$7K |
| D1120 |
Prophylaxis - child |
121 |
121 |
$4K |
| D1206 |
Topical application of fluoride varnish |
186 |
185 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
299 |
$2K |
| D1330 |
|
134 |
134 |
$1K |
| D1310 |
|
133 |
133 |
$1K |
| D2954 |
|
16 |
14 |
$994.40 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$900.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$84.00 |