| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,207 |
749 |
$93K |
| D1110 |
Prophylaxis - adult |
1,786 |
1,786 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,756 |
1,756 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
579 |
368 |
$49K |
| D1120 |
Prophylaxis - child |
1,213 |
1,213 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,865 |
1,865 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,838 |
1,838 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,083 |
2,083 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
383 |
281 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
435 |
435 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,233 |
1,214 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
116 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$443.59 |