| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
705 |
184 |
$70K |
| D7510 |
|
455 |
161 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
835 |
764 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
457 |
453 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
567 |
$21K |
| D1110 |
Prophylaxis - adult |
258 |
255 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
687 |
$9K |
| D4341 |
|
108 |
41 |
$8K |
| D7250 |
|
42 |
12 |
$5K |
| D4910 |
|
53 |
52 |
$4K |
| D4355 |
|
69 |
66 |
$3K |
| D2332 |
|
29 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
92 |
90 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
75 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$836.00 |
| D1999 |
|
85 |
70 |
$574.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$290.00 |
| D1330 |
|
29 |
29 |
$130.00 |