| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
592 |
280 |
$43K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$7K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
118 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
23 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
113 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
18 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
36 |
$494.95 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$136.90 |