| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
242 |
229 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
44 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
232 |
$2K |
| D4355 |
|
18 |
18 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
25 |
$995.40 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$806.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
60 |
$493.46 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$381.38 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$325.00 |