| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
770 |
235 |
$129K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
227 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
294 |
$12K |
| D0330 |
Panoramic radiographic image |
139 |
138 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
206 |
$9K |
| D1110 |
Prophylaxis - adult |
126 |
120 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
203 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
67 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
144 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
42 |
$626.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
53 |
$420.00 |