| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
59 |
$11K |
| D1110 |
Prophylaxis - adult |
176 |
175 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
257 |
$7K |
| D1120 |
Prophylaxis - child |
189 |
189 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
136 |
$6K |
| D0330 |
Panoramic radiographic image |
110 |
107 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$4K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |