| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
418 |
144 |
$41K |
| D2750 |
|
19 |
12 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
165 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
28 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
86 |
$2K |
| D0274 |
Bitewings - four radiographic images |
122 |
112 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
42 |
$2K |
| D2950 |
|
25 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
74 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
71 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$617.00 |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
94 |
$513.40 |