| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,774 |
694 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
962 |
648 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,033 |
542 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,348 |
1,215 |
$33K |
| D1110 |
Prophylaxis - adult |
986 |
897 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,451 |
1,269 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,855 |
2,450 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
857 |
795 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,330 |
1,215 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
999 |
910 |
$12K |
| D1120 |
Prophylaxis - child |
555 |
501 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,429 |
1,684 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
179 |
133 |
$10K |
| D1351 |
Sealant - per tooth |
505 |
88 |
$10K |
| D9110 |
|
255 |
237 |
$10K |
| D4341 |
|
406 |
142 |
$8K |
| D2332 |
|
159 |
95 |
$8K |
| D1206 |
Topical application of fluoride varnish |
497 |
457 |
$6K |
| D2331 |
|
107 |
53 |
$5K |
| D2330 |
|
100 |
64 |
$3K |
| D0330 |
Panoramic radiographic image |
94 |
87 |
$2K |
| D9920 |
|
44 |
42 |
$1K |
| D1354 |
|
278 |
79 |
$714.00 |
| D0272 |
Bitewings - two radiographic images |
42 |
41 |
$338.31 |