| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,186 |
379 |
$106K |
| D1110 |
Prophylaxis - adult |
1,249 |
1,246 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,571 |
1,570 |
$45K |
| D0330 |
Panoramic radiographic image |
1,150 |
1,148 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,262 |
1,262 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,102 |
1,101 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
107 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
660 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
441 |
441 |
$6K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
152 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$450.00 |