| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
151 |
59 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
177 |
$9K |
| D0330 |
Panoramic radiographic image |
189 |
178 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
32 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
325 |
125 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
71 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
66 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
75 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
25 |
$845.48 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$744.60 |