| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
274 |
265 |
$6K |
| D1110 |
Prophylaxis - adult |
159 |
159 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
29 |
$5K |
| D9630 |
|
187 |
186 |
$3K |
| D1206 |
Topical application of fluoride varnish |
154 |
153 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
171 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
16 |
$920.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$845.37 |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$556.20 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$441.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
24 |
$404.88 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$0.00 |