| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
306 |
126 |
$50K |
| D1110 |
Prophylaxis - adult |
534 |
534 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
191 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
57 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
274 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
476 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
396 |
387 |
$6K |
| D1120 |
Prophylaxis - child |
182 |
182 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
32 |
$2K |
| D2332 |
|
22 |
12 |
$882.06 |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$361.56 |
| D0220 |
Intraoral - periapical first radiographic image |
558 |
544 |
$93.19 |
| D1206 |
Topical application of fluoride varnish |
411 |
411 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
357 |
204 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$0.00 |