| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
4,151 |
1,029 |
$256K |
| D1110 |
Prophylaxis - adult |
5,483 |
4,728 |
$228K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,403 |
767 |
$224K |
| D0330 |
Panoramic radiographic image |
4,026 |
3,563 |
$186K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,648 |
1,467 |
$170K |
| D0274 |
Bitewings - four radiographic images |
4,961 |
4,263 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,513 |
5,146 |
$112K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,310 |
872 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,717 |
3,058 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,845 |
2,583 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,128 |
701 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
2,141 |
1,829 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
7,063 |
5,987 |
$41K |
| D2394 |
|
374 |
288 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
35 |
24 |
$28K |
| D2332 |
|
319 |
190 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,413 |
1,127 |
$26K |
| D5110 |
|
56 |
39 |
$24K |
| D1120 |
Prophylaxis - child |
973 |
813 |
$22K |
| D4341 |
|
226 |
73 |
$21K |
| D9243 |
|
280 |
84 |
$15K |
| D2331 |
|
195 |
106 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
757 |
732 |
$12K |
| D2950 |
|
152 |
119 |
$12K |
| D0272 |
Bitewings - two radiographic images |
683 |
585 |
$7K |
| D9239 |
|
92 |
84 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
282 |
125 |
$7K |
| D7230 |
|
30 |
13 |
$5K |
| D1351 |
Sealant - per tooth |
141 |
34 |
$3K |
| D2335 |
|
22 |
14 |
$2K |
| D1354 |
|
83 |
24 |
$1K |
| D4910 |
|
35 |
28 |
$1K |
| D0270 |
|
80 |
63 |
$361.78 |
| D9610 |
|
12 |
12 |
$0.00 |