| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
305 |
147 |
$27K |
| D0330 |
Panoramic radiographic image |
329 |
329 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
294 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
197 |
$7K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
33 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
390 |
380 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
259 |
259 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$533.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
281 |
$528.00 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$400.00 |