| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
123 |
66 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
55 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
278 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
166 |
162 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
122 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
28 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
262 |
$4K |
| D2950 |
|
21 |
15 |
$4K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$900.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
42 |
$405.20 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$348.51 |