| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,239 |
647 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
37 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
208 |
$4K |
| D0330 |
Panoramic radiographic image |
101 |
86 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
146 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
268 |
$4K |
| D2950 |
|
198 |
176 |
$4K |
| D0274 |
Bitewings - four radiographic images |
159 |
148 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$3K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
323 |
288 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
61 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
30 |
$257.14 |