| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
468 |
209 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
537 |
537 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
482 |
481 |
$22K |
| D1120 |
Prophylaxis - child |
285 |
284 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,077 |
628 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
179 |
$7K |
| D4341 |
|
96 |
26 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
43 |
$5K |
| D0272 |
Bitewings - two radiographic images |
470 |
468 |
$5K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
64 |
38 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
110 |
110 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
99 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$172.00 |