| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
394 |
66 |
$93K |
| D2740 |
Crown - porcelain/ceramic |
134 |
78 |
$65K |
| D0330 |
Panoramic radiographic image |
403 |
384 |
$36K |
| D0274 |
Bitewings - four radiographic images |
550 |
530 |
$31K |
| D1351 |
Sealant - per tooth |
506 |
32 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
40 |
$19K |
| D2950 |
|
94 |
70 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
259 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
187 |
$9K |
| D1110 |
Prophylaxis - adult |
92 |
91 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
139 |
136 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$659.61 |