| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
189 |
76 |
$14K |
| D1110 |
Prophylaxis - adult |
136 |
118 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
117 |
$5K |
| D0274 |
Bitewings - four radiographic images |
102 |
82 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
43 |
32 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
24 |
$650.48 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$385.74 |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
20 |
$368.16 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
31 |
$334.13 |