| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
27 |
$6K |
| D1120 |
Prophylaxis - child |
119 |
117 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
131 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
134 |
132 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
166 |
$2K |
| D1110 |
Prophylaxis - adult |
64 |
62 |
$2K |
| D0274 |
Bitewings - four radiographic images |
93 |
90 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
93 |
$736.64 |