| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
171 |
69 |
$10K |
| D1110 |
Prophylaxis - adult |
249 |
244 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
93 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
86 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
186 |
$5K |
| D0330 |
Panoramic radiographic image |
87 |
86 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
162 |
$4K |
| D2950 |
|
51 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
172 |
167 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
189 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
93 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$975.00 |
| D1120 |
Prophylaxis - child |
40 |
39 |
$800.00 |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
110 |
$550.00 |