| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
702 |
245 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
1,044 |
884 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
521 |
268 |
$40K |
| D1110 |
Prophylaxis - adult |
733 |
733 |
$33K |
| D2954 |
|
244 |
187 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
499 |
497 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
28 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
701 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
150 |
$15K |
| D2335 |
|
106 |
56 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
72 |
$10K |
| D2332 |
|
114 |
68 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,086 |
946 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
313 |
$8K |
| D4341 |
|
76 |
29 |
$7K |
| D1120 |
Prophylaxis - child |
96 |
96 |
$4K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$4K |
| D2330 |
|
68 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
222 |
222 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$3K |
| D0270 |
|
308 |
292 |
$2K |
| D2331 |
|
36 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
489 |
472 |
$2K |
| D4910 |
|
17 |
17 |
$2K |
| D2950 |
|
17 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$406.25 |