| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
358 |
224 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
576 |
$38K |
| D1110 |
Prophylaxis - adult |
430 |
430 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
403 |
183 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
459 |
459 |
$22K |
| D0350 |
|
1,316 |
420 |
$12K |
| D0330 |
Panoramic radiographic image |
345 |
344 |
$10K |
| D9430 |
|
305 |
287 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
540 |
540 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
85 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$6K |
| D1351 |
Sealant - per tooth |
120 |
26 |
$5K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$4K |
| D4341 |
|
60 |
15 |
$4K |
| D2330 |
|
40 |
12 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
176 |
124 |
$708.75 |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$540.00 |