| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
100 |
$8K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
203 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
181 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
202 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
227 |
$4K |
| D0330 |
Panoramic radiographic image |
95 |
91 |
$2K |
| D0274 |
Bitewings - four radiographic images |
108 |
107 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
219 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$818.55 |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
65 |
$802.60 |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$710.60 |
| D9310 |
|
12 |
12 |
$188.10 |