| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,209 |
544 |
$139K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,708 |
1,529 |
$87K |
| D0330 |
Panoramic radiographic image |
1,679 |
1,658 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,947 |
1,100 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,707 |
2,684 |
$36K |
| D1206 |
Topical application of fluoride varnish |
3,312 |
3,290 |
$33K |
| D1110 |
Prophylaxis - adult |
1,785 |
1,774 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,844 |
1,823 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,686 |
1,629 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
943 |
461 |
$26K |
| D1120 |
Prophylaxis - child |
1,869 |
1,855 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
887 |
636 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,355 |
1,343 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
226 |
136 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,758 |
1,688 |
$13K |
| D0272 |
Bitewings - two radiographic images |
906 |
900 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,862 |
1,030 |
$10K |
| D2335 |
|
228 |
157 |
$7K |
| D2331 |
|
193 |
148 |
$6K |
| D2160 |
|
56 |
41 |
$5K |
| D9243 |
|
18 |
14 |
$3K |
| D1351 |
Sealant - per tooth |
352 |
130 |
$3K |
| D9239 |
|
16 |
14 |
$2K |
| D2394 |
|
161 |
130 |
$2K |
| D2330 |
|
74 |
56 |
$2K |
| D1330 |
|
326 |
324 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D2140 |
|
17 |
13 |
$959.34 |
| D1310 |
|
309 |
306 |
$0.00 |
| D4355 |
|
12 |
12 |
$0.00 |
| D5110 |
|
12 |
12 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$0.00 |
| D2332 |
|
30 |
24 |
$0.00 |