| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,168 |
470 |
$79K |
| D9310 |
|
665 |
664 |
$36K |
| D1110 |
Prophylaxis - adult |
654 |
654 |
$27K |
| D0330 |
Panoramic radiographic image |
513 |
512 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
417 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
474 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
708 |
694 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
53 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
335 |
331 |
$4K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
267 |
262 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$984.93 |