| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
178 |
54 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,057 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
239 |
82 |
$25K |
| D1110 |
Prophylaxis - adult |
365 |
364 |
$23K |
| D9310 |
|
412 |
371 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
409 |
407 |
$9K |
| D1120 |
Prophylaxis - child |
211 |
208 |
$9K |
| D1206 |
Topical application of fluoride varnish |
239 |
235 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
307 |
290 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
66 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$741.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$735.20 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$437.34 |
| D1330 |
|
17 |
17 |
$122.40 |