| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
469 |
460 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
714 |
149 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
265 |
79 |
$16K |
| D1110 |
Prophylaxis - adult |
291 |
278 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
583 |
$4K |
| D1206 |
Topical application of fluoride varnish |
329 |
318 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
62 |
$499.40 |
| D1330 |
|
260 |
250 |
$159.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$45.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
60 |
$10.00 |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
148 |
$9.02 |
| D4921 |
|
873 |
308 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
18 |
$0.00 |