| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
43 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
26 |
$1K |
| D2394 |
|
27 |
12 |
$990.40 |
| D1110 |
Prophylaxis - adult |
156 |
101 |
$506.16 |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
28 |
$289.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
32 |
$284.00 |
| D0120 |
Periodic oral evaluation - established patient |
186 |
132 |
$255.15 |
| D0274 |
Bitewings - four radiographic images |
77 |
41 |
$150.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
39 |
$44.78 |