| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
999 |
426 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,551 |
1,518 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
865 |
841 |
$30K |
| D1351 |
Sealant - per tooth |
589 |
68 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
132 |
$17K |
| D1110 |
Prophylaxis - adult |
389 |
385 |
$11K |
| D0330 |
Panoramic radiographic image |
270 |
266 |
$9K |
| D1120 |
Prophylaxis - child |
184 |
184 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
52 |
$6K |
| D0274 |
Bitewings - four radiographic images |
262 |
259 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
79 |
34 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
287 |
285 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
30 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
143 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
261 |
209 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
243 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
14 |
$1K |
| D2950 |
|
20 |
15 |
$1K |
| D2140 |
|
25 |
12 |
$894.65 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$112.80 |