| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
4,292 |
2,019 |
$498K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,870 |
3,863 |
$232K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
391 |
296 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
2,536 |
2,523 |
$137K |
| D0210 |
Intraoral - complete series of radiographic images |
2,882 |
2,877 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,547 |
990 |
$102K |
| D4341 |
|
1,434 |
435 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,229 |
5,159 |
$85K |
| D9430 |
|
2,626 |
2,550 |
$82K |
| D1120 |
Prophylaxis - child |
1,939 |
1,929 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,176 |
464 |
$67K |
| D7230 |
|
338 |
185 |
$64K |
| D4910 |
|
798 |
798 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
948 |
635 |
$50K |
| D0350 |
|
3,661 |
1,463 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,659 |
1,652 |
$34K |
| D0330 |
Panoramic radiographic image |
1,142 |
1,138 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,664 |
2,642 |
$29K |
| D1110 |
Prophylaxis - adult |
328 |
328 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,289 |
1,280 |
$15K |
| D0250 |
|
521 |
507 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
110 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
35 |
14 |
$8K |
| D1351 |
Sealant - per tooth |
221 |
67 |
$5K |
| D0260 |
|
551 |
337 |
$3K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$2K |
| D0270 |
|
126 |
123 |
$620.00 |