| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
484 |
112 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
178 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
442 |
437 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
538 |
530 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
26 |
13 |
$13K |
| D4342 |
|
348 |
93 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
56 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
32 |
$4K |
| D1110 |
Prophylaxis - adult |
74 |
72 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$3K |
| D0330 |
Panoramic radiographic image |
91 |
84 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
73 |
$2K |
| D0367 |
|
26 |
23 |
$601.44 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
64 |
$409.92 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$293.15 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
12 |
$287.21 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
54 |
$177.74 |