| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
869 |
207 |
$109K |
| D1110 |
Prophylaxis - adult |
1,125 |
1,085 |
$46K |
| D0330 |
Panoramic radiographic image |
1,076 |
1,030 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
603 |
157 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,272 |
1,226 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,593 |
1,545 |
$34K |
| D1120 |
Prophylaxis - child |
652 |
638 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
738 |
$18K |
| D0274 |
Bitewings - four radiographic images |
704 |
680 |
$16K |
| D1351 |
Sealant - per tooth |
312 |
96 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
16 |
12 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
60 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
64 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
238 |
207 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
163 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
207 |
$3K |
| D4355 |
|
34 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
126 |
124 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
68 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
26 |
$492.50 |