| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
364 |
118 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
100 |
$10K |
| D1120 |
Prophylaxis - child |
194 |
190 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
361 |
$8K |
| D1206 |
Topical application of fluoride varnish |
182 |
180 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
205 |
$3K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
359 |
$2K |
| D0274 |
Bitewings - four radiographic images |
113 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
234 |
$978.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$647.85 |
| D0120 |
Periodic oral evaluation - established patient |
21 |
16 |
$588.00 |