| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
257 |
124 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,262 |
884 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,954 |
1,946 |
$3K |
| D1110 |
Prophylaxis - adult |
1,115 |
1,083 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
939 |
431 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
1,853 |
1,822 |
$2K |
| D1206 |
Topical application of fluoride varnish |
2,562 |
2,505 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
752 |
517 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,960 |
2,904 |
$1K |
| D1120 |
Prophylaxis - child |
1,189 |
1,177 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,238 |
1,212 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
934 |
930 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
520 |
519 |
$573.17 |
| D0330 |
Panoramic radiographic image |
845 |
842 |
$505.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,197 |
1,876 |
$495.74 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
199 |
148 |
$280.63 |
| D0270 |
|
571 |
566 |
$160.01 |
| D2950 |
|
48 |
37 |
$135.11 |
| D1351 |
Sealant - per tooth |
316 |
139 |
$42.48 |
| D0272 |
Bitewings - two radiographic images |
53 |
52 |
$16.73 |
| D0190 |
|
244 |
237 |
$0.00 |
| D9987 |
|
203 |
198 |
$0.00 |
| D2332 |
|
35 |
26 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
316 |
310 |
$0.00 |
| D2931 |
|
46 |
39 |
$0.00 |
| D4355 |
|
19 |
19 |
$0.00 |