| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
854 |
348 |
$98K |
| D1110 |
Prophylaxis - adult |
1,080 |
1,071 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
402 |
400 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
646 |
400 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
343 |
218 |
$31K |
| D1120 |
Prophylaxis - child |
380 |
380 |
$24K |
| D2332 |
|
47 |
26 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
568 |
551 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
896 |
889 |
$2K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$114.47 |
| D0120 |
Periodic oral evaluation - established patient |
509 |
506 |
$80.49 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
714 |
708 |
$-74.47 |
| D0220 |
Intraoral - periapical first radiographic image |
747 |
726 |
$-85.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
447 |
442 |
$-256.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
540 |
308 |
$-326.87 |