| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
895 |
405 |
$114K |
| D0140 |
Limited oral evaluation - problem focused |
3,451 |
3,086 |
$99K |
| D1110 |
Prophylaxis - adult |
1,758 |
1,594 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,480 |
1,315 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
240 |
$27K |
| D0330 |
Panoramic radiographic image |
659 |
591 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,941 |
2,579 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
796 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
480 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
738 |
460 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
36 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
42 |
$925.75 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$345.00 |