| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
436 |
160 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
548 |
545 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
850 |
829 |
$14K |
| D4355 |
|
287 |
285 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
26 |
$3K |
| D7310 |
|
28 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
125 |
$2K |
| D2332 |
|
33 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
18 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$653.00 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
53 |
$344.25 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$186.13 |