| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,267 |
839 |
$264K |
| D2740 |
Crown - porcelain/ceramic |
497 |
408 |
$236K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,675 |
2,663 |
$165K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
341 |
278 |
$161K |
| D1110 |
Prophylaxis - adult |
1,377 |
1,367 |
$114K |
| D0210 |
Intraoral - complete series of radiographic images |
2,378 |
2,365 |
$111K |
| D4910 |
|
1,344 |
1,341 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
1,250 |
1,245 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
983 |
603 |
$65K |
| D4341 |
|
880 |
268 |
$62K |
| D0350 |
|
6,889 |
2,270 |
$59K |
| D9430 |
|
1,214 |
1,205 |
$38K |
| D2954 |
|
320 |
275 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,386 |
1,378 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,377 |
2,300 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,994 |
2,691 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,659 |
1,644 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
358 |
206 |
$19K |
| D0330 |
Panoramic radiographic image |
556 |
555 |
$16K |
| D1120 |
Prophylaxis - child |
357 |
354 |
$13K |
| D1206 |
Topical application of fluoride varnish |
675 |
675 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
27 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0270 |
|
14 |
14 |
$68.75 |