| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
14 |
$5K |
| D1110 |
Prophylaxis - adult |
145 |
129 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
130 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
38 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
42 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
67 |
$2K |
| D0274 |
Bitewings - four radiographic images |
61 |
51 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
48 |
$766.99 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$170.35 |