| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
240 |
83 |
$29K |
| D1110 |
Prophylaxis - adult |
458 |
403 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
479 |
$15K |
| D0274 |
Bitewings - four radiographic images |
400 |
342 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
678 |
323 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
418 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
115 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
207 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
14 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
72 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
167 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
73 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$276.00 |