| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,119 |
379 |
$128K |
| D1110 |
Prophylaxis - adult |
914 |
913 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
985 |
985 |
$48K |
| D5211 |
|
99 |
97 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,998 |
1,351 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,117 |
1,115 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
176 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,154 |
1,153 |
$11K |
| D5212 |
|
27 |
26 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
80 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
481 |
$6K |
| D2332 |
|
29 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
59 |
$2K |
| D0350 |
|
283 |
157 |
$2K |
| D2330 |
|
24 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$150.00 |