| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,114 |
593 |
$122K |
| D1110 |
Prophylaxis - adult |
997 |
997 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,601 |
1,600 |
$48K |
| D2750 |
|
80 |
38 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,510 |
1,510 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
173 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
836 |
836 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
894 |
892 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,057 |
1,045 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
111 |
$9K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$5K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
184 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
95 |
$1K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$420.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$125.02 |
| D1999 |
|
74 |
71 |
$0.00 |