| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
339 |
96 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
381 |
$16K |
| D0330 |
Panoramic radiographic image |
318 |
308 |
$14K |
| D1110 |
Prophylaxis - adult |
252 |
244 |
$13K |
| D0274 |
Bitewings - four radiographic images |
280 |
268 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
188 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
316 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
285 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
335 |
173 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
73 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
85 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
82 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$268.68 |