| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,039 |
631 |
$221K |
| D1110 |
Prophylaxis - adult |
1,901 |
1,898 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
726 |
726 |
$75K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,188 |
659 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,988 |
1,012 |
$55K |
| D9420 |
|
401 |
396 |
$35K |
| D2332 |
|
124 |
77 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,296 |
1,274 |
$19K |
| D4341 |
|
208 |
82 |
$14K |
| D2394 |
|
161 |
95 |
$12K |
| D0330 |
Panoramic radiographic image |
578 |
578 |
$12K |
| D4910 |
|
132 |
131 |
$8K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
662 |
399 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,027 |
1,026 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,295 |
1,290 |
$411.96 |
| D0120 |
Periodic oral evaluation - established patient |
1,452 |
1,450 |
$158.81 |
| D0220 |
Intraoral - periapical first radiographic image |
1,564 |
1,528 |
$30.41 |
| D1206 |
Topical application of fluoride varnish |
753 |
753 |
$27.10 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
24 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,115 |
627 |
$-185.15 |