| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
590 |
236 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
156 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
231 |
$6K |
| D2394 |
|
75 |
56 |
$5K |
| D0330 |
Panoramic radiographic image |
138 |
136 |
$5K |
| D2335 |
|
66 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
731 |
612 |
$5K |
| D0274 |
Bitewings - four radiographic images |
195 |
189 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
121 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
51 |
$3K |
| D1110 |
Prophylaxis - adult |
77 |
72 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
70 |
$646.35 |