| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
86 |
32 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
24 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
49 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$937.20 |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$542.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
22 |
$534.85 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$459.70 |
| D0330 |
Panoramic radiographic image |
23 |
21 |
$429.40 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$405.60 |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$364.60 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$351.80 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
22 |
$340.20 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$162.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$72.20 |