| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
866 |
262 |
$86K |
| D0330 |
Panoramic radiographic image |
819 |
776 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
784 |
720 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
601 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
109 |
$12K |
| D1110 |
Prophylaxis - adult |
306 |
288 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
771 |
670 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
60 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
148 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
70 |
$1K |
| D0274 |
Bitewings - four radiographic images |
51 |
47 |
$905.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
76 |
$633.16 |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$609.70 |