| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,235 |
342 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
698 |
458 |
$72K |
| D1110 |
Prophylaxis - adult |
954 |
954 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,358 |
1,358 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,535 |
1,534 |
$26K |
| D1120 |
Prophylaxis - child |
691 |
691 |
$21K |
| D0274 |
Bitewings - four radiographic images |
676 |
676 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,240 |
1,228 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
515 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,807 |
943 |
$14K |
| D0330 |
Panoramic radiographic image |
275 |
275 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
284 |
273 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
41 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
67 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
26 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
155 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
184 |
$3K |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$3K |