| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,622 |
488 |
$76K |
| D0140 |
Limited oral evaluation - problem focused |
914 |
770 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,551 |
1,337 |
$16K |
| D1110 |
Prophylaxis - adult |
607 |
551 |
$12K |
| D0274 |
Bitewings - four radiographic images |
560 |
491 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
467 |
$9K |
| D1120 |
Prophylaxis - child |
203 |
192 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,388 |
1,052 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
176 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
71 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
136 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$618.04 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$390.00 |