| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
359 |
54 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
317 |
316 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
494 |
465 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
362 |
362 |
$14K |
| D1110 |
Prophylaxis - adult |
265 |
264 |
$12K |
| D4341 |
|
89 |
40 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
334 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
354 |
346 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$406.00 |
| D9986 |
|
28 |
27 |
$0.00 |