| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
334 |
111 |
$57K |
| D1110 |
Prophylaxis - adult |
618 |
576 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
841 |
767 |
$48K |
| D0274 |
Bitewings - four radiographic images |
750 |
692 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
133 |
$39K |
| D0330 |
Panoramic radiographic image |
375 |
351 |
$33K |
| D2740 |
Crown - porcelain/ceramic |
31 |
28 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
387 |
358 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
91 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
817 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
454 |
395 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
15 |
$8K |
| D2950 |
|
29 |
25 |
$5K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$712.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
12 |
$684.12 |