| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
121 |
58 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
147 |
$10K |
| D1110 |
Prophylaxis - adult |
144 |
140 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
204 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
44 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
73 |
$5K |
| D1330 |
|
103 |
102 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$3K |
| D1206 |
Topical application of fluoride varnish |
131 |
126 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
79 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
250 |
$3K |
| D0274 |
Bitewings - four radiographic images |
30 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$279.14 |