| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
668 |
147 |
$106K |
| D1110 |
Prophylaxis - adult |
1,821 |
1,731 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,020 |
1,907 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,033 |
968 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
682 |
625 |
$24K |
| D1120 |
Prophylaxis - child |
839 |
787 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
588 |
537 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
458 |
172 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
121 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
773 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
431 |
392 |
$5K |
| D2394 |
|
47 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
184 |
174 |
$3K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$954.92 |
| D1999 |
|
220 |
202 |
$169.79 |