| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
634 |
178 |
$128K |
| D1110 |
Prophylaxis - adult |
1,550 |
1,419 |
$120K |
| D0330 |
Panoramic radiographic image |
1,333 |
1,219 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
261 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,326 |
1,229 |
$78K |
| D0274 |
Bitewings - four radiographic images |
1,453 |
1,327 |
$78K |
| D2740 |
Crown - porcelain/ceramic |
127 |
73 |
$64K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
304 |
125 |
$53K |
| D2950 |
|
252 |
154 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,393 |
1,272 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
423 |
396 |
$25K |
| D9243 |
|
76 |
45 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
237 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
371 |
$9K |
| D1351 |
Sealant - per tooth |
151 |
13 |
$8K |
| D9239 |
|
78 |
47 |
$5K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$4K |