| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
644 |
259 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,023 |
1,021 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
634 |
327 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
838 |
836 |
$36K |
| D1110 |
Prophylaxis - adult |
409 |
408 |
$30K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
63 |
48 |
$28K |
| D4341 |
|
348 |
105 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
393 |
158 |
$20K |
| D1120 |
Prophylaxis - child |
569 |
568 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
416 |
415 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,793 |
719 |
$14K |
| D0350 |
|
1,075 |
446 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
75 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
892 |
890 |
$8K |
| D0274 |
Bitewings - four radiographic images |
411 |
411 |
$6K |
| D9430 |
|
162 |
161 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
413 |
$5K |
| D1351 |
Sealant - per tooth |
214 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$342.00 |