| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,947 |
1,944 |
$158K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,519 |
468 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,109 |
1,008 |
$88K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
504 |
303 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
532 |
530 |
$44K |
| D1120 |
Prophylaxis - child |
508 |
507 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,063 |
1,062 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
929 |
924 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
301 |
180 |
$7K |
| D0330 |
Panoramic radiographic image |
131 |
131 |
$4K |
| D4341 |
|
42 |
14 |
$3K |
| D4355 |
|
26 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,796 |
1,792 |
$1K |
| D4910 |
|
12 |
12 |
$764.32 |
| D0120 |
Periodic oral evaluation - established patient |
2,582 |
2,577 |
$512.47 |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
593 |
$467.53 |
| D2331 |
|
15 |
12 |
$299.98 |
| D0220 |
Intraoral - periapical first radiographic image |
3,946 |
3,907 |
$185.90 |
| D1206 |
Topical application of fluoride varnish |
1,837 |
1,834 |
$41.94 |
| D0272 |
Bitewings - two radiographic images |
299 |
298 |
$0.00 |
| D1999 |
|
14 |
14 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,256 |
2,861 |
$-247.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,034 |
909 |
$-883.05 |