| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
504 |
103 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
283 |
$12K |
| D1110 |
Prophylaxis - adult |
164 |
157 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
147 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
351 |
314 |
$5K |
| D0330 |
Panoramic radiographic image |
86 |
84 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
391 |
152 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
19 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
57 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D4355 |
|
13 |
13 |
$882.64 |
| D1206 |
Topical application of fluoride varnish |
41 |
38 |
$620.86 |