| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
623 |
252 |
$115K |
| D1110 |
Prophylaxis - adult |
1,133 |
1,056 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
549 |
518 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
279 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,317 |
1,234 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
732 |
688 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
553 |
522 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
719 |
675 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
83 |
75 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
65 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
28 |
$1K |