| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
378 |
147 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
593 |
543 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
624 |
583 |
$12K |
| D1110 |
Prophylaxis - adult |
280 |
268 |
$11K |
| D0274 |
Bitewings - four radiographic images |
329 |
306 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
212 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
62 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
288 |
266 |
$4K |
| D0330 |
Panoramic radiographic image |
74 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
92 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
24 |
$759.00 |