| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
250 |
148 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
803 |
801 |
$29K |
| D1110 |
Prophylaxis - adult |
591 |
591 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
480 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
1,137 |
$14K |
| D0274 |
Bitewings - four radiographic images |
284 |
284 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
634 |
603 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
24 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$4K |
| D2394 |
|
29 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$3K |
| D1206 |
Topical application of fluoride varnish |
125 |
125 |
$2K |