| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,162 |
1,160 |
$52K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
515 |
222 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,151 |
1,146 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
679 |
263 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
681 |
678 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
51 |
31 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
173 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
213 |
122 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
813 |
811 |
$22K |
| D1120 |
Prophylaxis - child |
479 |
479 |
$19K |
| D0274 |
Bitewings - four radiographic images |
480 |
479 |
$14K |
| D2950 |
|
88 |
53 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
559 |
559 |
$12K |
| D2710 |
|
17 |
14 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
837 |
831 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
60 |
$8K |
| D7240 |
Removal of impacted tooth - completely bony |
23 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
146 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
496 |
462 |
$4K |
| D4355 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$258.00 |