| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
881 |
217 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,046 |
388 |
$126K |
| D2740 |
Crown - porcelain/ceramic |
345 |
213 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,947 |
1,465 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
977 |
802 |
$60K |
| D0330 |
Panoramic radiographic image |
1,065 |
734 |
$60K |
| D1110 |
Prophylaxis - adult |
1,024 |
704 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,247 |
894 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
863 |
659 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
91 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,546 |
1,168 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,404 |
1,090 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
705 |
547 |
$22K |
| D2950 |
|
159 |
125 |
$22K |
| D1351 |
Sealant - per tooth |
289 |
37 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
36 |
$7K |
| D1120 |
Prophylaxis - child |
135 |
122 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
523 |
264 |
$6K |
| D2394 |
|
16 |
12 |
$3K |
| D0270 |
|
34 |
24 |
$500.83 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
32 |
$0.00 |