| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,096 |
650 |
$93K |
| D4341 |
|
533 |
304 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,157 |
755 |
$79K |
| D1120 |
Prophylaxis - child |
1,264 |
1,216 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,693 |
1,638 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,742 |
1,620 |
$41K |
| D0330 |
Panoramic radiographic image |
1,203 |
1,163 |
$24K |
| D1110 |
Prophylaxis - adult |
512 |
500 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
786 |
750 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
204 |
155 |
$17K |
| D0274 |
Bitewings - four radiographic images |
886 |
845 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
445 |
382 |
$10K |
| D1351 |
Sealant - per tooth |
134 |
60 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,024 |
937 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,688 |
1,537 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
103 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
139 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
566 |
460 |
$2K |
| D2950 |
|
14 |
13 |
$754.65 |