| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
285 |
108 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
239 |
$5K |
| D4341 |
|
230 |
60 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
49 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
151 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
508 |
441 |
$3K |
| D0330 |
Panoramic radiographic image |
141 |
124 |
$2K |
| D0274 |
Bitewings - four radiographic images |
308 |
267 |
$2K |
| D1110 |
Prophylaxis - adult |
55 |
52 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
73 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
81 |
$938.88 |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
26 |
$636.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
521 |
306 |
$588.24 |