| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
135 |
135 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
124 |
47 |
$11K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
62 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
61 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
139 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
196 |
$968.71 |
| D2331 |
|
19 |
14 |
$697.91 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
25 |
$541.59 |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
133 |
$9.22 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$0.00 |