| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
640 |
294 |
$37K |
| D4341 |
|
1,335 |
372 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
704 |
423 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
433 |
276 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
796 |
741 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
450 |
$11K |
| D0330 |
Panoramic radiographic image |
546 |
504 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
285 |
153 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,431 |
1,260 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
344 |
$7K |
| D0274 |
Bitewings - four radiographic images |
792 |
756 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
381 |
373 |
$5K |
| D4910 |
|
60 |
58 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,083 |
989 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$525.05 |
| D0180 |
|
41 |
39 |
$0.00 |