| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,624 |
953 |
$192K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
365 |
257 |
$173K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,226 |
2,225 |
$140K |
| D1110 |
Prophylaxis - adult |
1,447 |
1,445 |
$123K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,795 |
1,023 |
$120K |
| D9430 |
|
3,251 |
2,939 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
1,900 |
1,900 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,785 |
868 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,149 |
4,204 |
$85K |
| D0274 |
Bitewings - four radiographic images |
2,708 |
2,705 |
$57K |
| D4341 |
|
779 |
219 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
685 |
685 |
$33K |
| D4260 |
|
47 |
12 |
$23K |
| D1120 |
Prophylaxis - child |
565 |
565 |
$18K |
| D0350 |
|
2,043 |
863 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,454 |
1,438 |
$17K |
| D2954 |
|
153 |
117 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
39 |
$4K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$3K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |
| D1999 |
|
52 |
51 |
$0.00 |