| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
948 |
560 |
$139K |
| D1110 |
Prophylaxis - adult |
1,584 |
1,499 |
$80K |
| D0140 |
Limited oral evaluation - problem focused |
1,309 |
1,273 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,490 |
1,400 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
682 |
656 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,404 |
1,353 |
$21K |
| D0274 |
Bitewings - four radiographic images |
550 |
516 |
$19K |
| D1120 |
Prophylaxis - child |
357 |
339 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
25 |
12 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
513 |
496 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,062 |
780 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
162 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
57 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
47 |
$6K |
| D0180 |
|
17 |
16 |
$639.00 |