| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
227 |
144 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
301 |
300 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
259 |
$13K |
| D1110 |
Prophylaxis - adult |
133 |
132 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,504 |
575 |
$6K |
| D9430 |
|
186 |
178 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
440 |
$5K |
| D2330 |
|
66 |
45 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
232 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
27 |
$2K |
| D2394 |
|
15 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$540.00 |