| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,848 |
709 |
$154K |
| D1110 |
Prophylaxis - adult |
2,590 |
2,586 |
$117K |
| D0210 |
Intraoral - complete series of radiographic images |
1,300 |
1,299 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,498 |
1,498 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,142 |
1,141 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,026 |
1,022 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
462 |
135 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
139 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,570 |
1,485 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
122 |
$15K |
| D9110 |
|
380 |
371 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
828 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
37 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
186 |
$3K |
| D2394 |
|
15 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$473.00 |