| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
698 |
165 |
$86K |
| D1110 |
Prophylaxis - adult |
936 |
895 |
$42K |
| D0330 |
Panoramic radiographic image |
758 |
725 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
186 |
$34K |
| D0274 |
Bitewings - four radiographic images |
825 |
800 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
761 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
960 |
925 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
599 |
573 |
$17K |
| D1120 |
Prophylaxis - child |
456 |
435 |
$14K |
| D1206 |
Topical application of fluoride varnish |
779 |
756 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
787 |
750 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
26 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$384.16 |