| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
839 |
294 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,123 |
1,100 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
1,239 |
884 |
$13K |
| D0330 |
Panoramic radiographic image |
359 |
350 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
924 |
596 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
568 |
363 |
$9K |
| D0274 |
Bitewings - four radiographic images |
852 |
835 |
$8K |
| D1110 |
Prophylaxis - adult |
659 |
645 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
1,043 |
956 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
710 |
685 |
$2K |
| D9310 |
|
55 |
55 |
$1K |
| D9994 |
|
1,082 |
1,060 |
$1K |
| D4341 |
|
659 |
224 |
$484.32 |
| D0270 |
|
33 |
32 |
$479.49 |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
144 |
$324.36 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
370 |
290 |
$299.70 |
| D9996 |
|
16 |
16 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
103 |
73 |
$0.00 |
| D2950 |
|
121 |
91 |
$0.00 |
| D4910 |
|
101 |
101 |
$0.00 |
| D7880 |
|
15 |
15 |
$0.00 |
| D1120 |
Prophylaxis - child |
27 |
27 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
185 |
176 |
$0.00 |
| D2394 |
|
14 |
12 |
$0.00 |
| D9110 |
|
14 |
14 |
$0.00 |
| D2332 |
|
25 |
16 |
$0.00 |
| D9219 |
|
16 |
16 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
438 |
438 |
$0.00 |
| D9630 |
|
403 |
395 |
$0.00 |
| D9920 |
|
225 |
219 |
$0.00 |
| D9995 |
|
495 |
464 |
$0.00 |
| D3120 |
|
247 |
165 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
209 |
$0.00 |
| D4355 |
|
133 |
132 |
$0.00 |
| D2335 |
|
15 |
12 |
$0.00 |
| D2330 |
|
23 |
16 |
$0.00 |
| D2331 |
|
15 |
12 |
$0.00 |