| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
48 |
12 |
$8K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
297 |
112 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
122 |
122 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
132 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$622.00 |