| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
776 |
129 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
424 |
175 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
571 |
202 |
$33K |
| D2394 |
|
301 |
113 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
432 |
244 |
$16K |
| D2332 |
|
247 |
78 |
$13K |
| D2335 |
|
178 |
66 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
542 |
312 |
$11K |
| D1110 |
Prophylaxis - adult |
413 |
265 |
$10K |
| D7250 |
|
206 |
17 |
$9K |
| D5110 |
|
21 |
16 |
$8K |
| D0330 |
Panoramic radiographic image |
269 |
154 |
$7K |
| D4355 |
|
151 |
103 |
$7K |
| D5120 |
|
13 |
12 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
136 |
$6K |
| D2331 |
|
97 |
44 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
22 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
172 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
94 |
$2K |
| D0274 |
Bitewings - four radiographic images |
97 |
69 |
$2K |
| D0170 |
|
109 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
31 |
$535.99 |