| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,795 |
1,672 |
$327K |
| D1110 |
Prophylaxis - adult |
2,544 |
2,535 |
$215K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,252 |
3,237 |
$205K |
| D0120 |
Periodic oral evaluation - established patient |
3,946 |
3,938 |
$194K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39,410 |
6,055 |
$169K |
| D2140 |
|
2,560 |
1,083 |
$138K |
| D9430 |
|
4,101 |
2,360 |
$129K |
| D0210 |
Intraoral - complete series of radiographic images |
2,665 |
2,648 |
$126K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,564 |
920 |
$103K |
| D1120 |
Prophylaxis - child |
3,044 |
3,034 |
$100K |
| D1206 |
Topical application of fluoride varnish |
5,722 |
5,700 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
927 |
502 |
$61K |
| D0272 |
Bitewings - two radiographic images |
4,985 |
4,964 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
855 |
423 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
824 |
451 |
$43K |
| D4341 |
|
552 |
147 |
$39K |
| D1351 |
Sealant - per tooth |
1,386 |
416 |
$29K |
| D2330 |
|
323 |
205 |
$25K |
| D4910 |
|
278 |
273 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,691 |
1,622 |
$20K |
| D9993 |
|
187 |
187 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
23 |
17 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
84 |
$9K |
| D1310 |
|
188 |
188 |
$8K |
| D2331 |
|
46 |
24 |
$4K |
| D2954 |
|
24 |
17 |
$2K |
| D2332 |
|
23 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$2K |
| D0603 |
|
39 |
39 |
$540.00 |