| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,124 |
415 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,204 |
555 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
826 |
825 |
$69K |
| D1110 |
Prophylaxis - adult |
1,464 |
1,461 |
$68K |
| D0330 |
Panoramic radiographic image |
933 |
928 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,173 |
482 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
40 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
630 |
624 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,306 |
1,305 |
$6K |
| D4341 |
|
103 |
40 |
$6K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D4910 |
|
15 |
15 |
$828.63 |
| D0274 |
Bitewings - four radiographic images |
1,136 |
1,133 |
$635.83 |
| D0120 |
Periodic oral evaluation - established patient |
874 |
873 |
$610.30 |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
25 |
$573.31 |
| D1208 |
Topical application of fluoride, excluding varnish |
593 |
592 |
$29.68 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
683 |
667 |
$-60.58 |