| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
475 |
120 |
$36K |
| D1110 |
Prophylaxis - adult |
848 |
794 |
$33K |
| D0330 |
Panoramic radiographic image |
776 |
700 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
787 |
708 |
$21K |
| D0274 |
Bitewings - four radiographic images |
673 |
617 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,099 |
1,034 |
$18K |
| D1120 |
Prophylaxis - child |
505 |
483 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
728 |
705 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,422 |
1,291 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,980 |
877 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
379 |
347 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
60 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
40 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
54 |
50 |
$1K |