| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,827 |
751 |
$324K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,057 |
564 |
$195K |
| D1110 |
Prophylaxis - adult |
3,418 |
3,158 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,575 |
3,293 |
$138K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,643 |
822 |
$134K |
| D0210 |
Intraoral - complete series of radiographic images |
2,001 |
1,774 |
$120K |
| D1351 |
Sealant - per tooth |
4,201 |
624 |
$119K |
| D0274 |
Bitewings - four radiographic images |
2,623 |
2,435 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,292 |
560 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,452 |
3,895 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,438 |
2,302 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
4,190 |
3,821 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
1,089 |
986 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,960 |
1,871 |
$42K |
| D1120 |
Prophylaxis - child |
1,156 |
1,114 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
243 |
86 |
$22K |
| D0330 |
Panoramic radiographic image |
359 |
342 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
86 |
$13K |
| D2335 |
|
72 |
39 |
$12K |
| D2140 |
|
62 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
98 |
96 |
$2K |
| D4355 |
|
13 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
30 |
27 |
$511.75 |