| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,017 |
391 |
$91K |
| D4341 |
|
267 |
133 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
699 |
686 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
152 |
$17K |
| D1120 |
Prophylaxis - child |
369 |
367 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
535 |
$15K |
| D0330 |
Panoramic radiographic image |
626 |
615 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
136 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
305 |
$8K |
| D0274 |
Bitewings - four radiographic images |
307 |
297 |
$5K |
| D2950 |
|
54 |
49 |
$4K |
| D0272 |
Bitewings - two radiographic images |
433 |
432 |
$4K |
| D1110 |
Prophylaxis - adult |
77 |
76 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
137 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
356 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$745.68 |