| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
495 |
260 |
$38K |
| D1120 |
Prophylaxis - child |
508 |
502 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
488 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
487 |
481 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
59 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
188 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
587 |
542 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
195 |
185 |
$3K |
| D0274 |
Bitewings - four radiographic images |
190 |
175 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
605 |
464 |
$3K |
| D1110 |
Prophylaxis - adult |
95 |
86 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$949.40 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$633.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$586.15 |