| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
529 |
191 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
153 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
449 |
449 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
793 |
779 |
$20K |
| D0330 |
Panoramic radiographic image |
949 |
941 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
423 |
$10K |
| D1999 |
|
1,110 |
933 |
$10K |
| D2954 |
|
94 |
87 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
18 |
15 |
$7K |
| D1110 |
Prophylaxis - adult |
163 |
162 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
580 |
576 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
261 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
29 |
$902.61 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$279.80 |