| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
423 |
125 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,020 |
885 |
$58K |
| D0330 |
Panoramic radiographic image |
694 |
684 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
349 |
70 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
136 |
$35K |
| D4341 |
|
204 |
70 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,621 |
350 |
$27K |
| D0274 |
Bitewings - four radiographic images |
529 |
522 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
93 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
75 |
$15K |
| D0180 |
|
185 |
183 |
$14K |
| D2335 |
|
85 |
44 |
$13K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$11K |
| D4342 |
|
72 |
29 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
388 |
366 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
131 |
$8K |
| D1351 |
Sealant - per tooth |
234 |
56 |
$8K |
| D1206 |
Topical application of fluoride varnish |
246 |
242 |
$6K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$5K |
| D2332 |
|
35 |
28 |
$4K |
| D9243 |
|
26 |
12 |
$4K |
| D2394 |
|
21 |
13 |
$4K |
| D9239 |
|
12 |
12 |
$2K |
| D2330 |
|
15 |
12 |
$1K |
| D0273 |
|
13 |
13 |
$542.49 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$460.85 |
| D1330 |
|
116 |
116 |
$398.70 |