| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
120 |
59 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
36 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
152 |
$4K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
32 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
219 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
158 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
148 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
77 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
30 |
$786.47 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$468.12 |