| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
721 |
212 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
254 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,477 |
989 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,622 |
1,458 |
$29K |
| D1120 |
Prophylaxis - child |
707 |
648 |
$27K |
| D0274 |
Bitewings - four radiographic images |
779 |
694 |
$21K |
| D1110 |
Prophylaxis - adult |
826 |
716 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
746 |
678 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
611 |
531 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
250 |
230 |
$10K |
| D2950 |
|
58 |
34 |
$4K |
| D0330 |
Panoramic radiographic image |
215 |
110 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
16 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
217 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
91 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D2140 |
|
23 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$846.66 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
12 |
$839.80 |