| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
796 |
361 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
890 |
369 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,782 |
1,189 |
$68K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
668 |
303 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
1,328 |
883 |
$62K |
| D1110 |
Prophylaxis - adult |
1,663 |
1,095 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
545 |
$17K |
| D0274 |
Bitewings - four radiographic images |
918 |
604 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
83 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
63 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$568.92 |
| D0140 |
Limited oral evaluation - problem focused |
133 |
87 |
$405.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$203.07 |