| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,627 |
803 |
$325K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,629 |
752 |
$240K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,228 |
635 |
$139K |
| D0140 |
Limited oral evaluation - problem focused |
3,400 |
3,253 |
$100K |
| D1110 |
Prophylaxis - adult |
1,793 |
1,726 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
5,370 |
5,127 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,601 |
2,558 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,586 |
4,387 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,208 |
1,150 |
$25K |
| D5225 |
|
38 |
38 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
615 |
$20K |
| D2394 |
|
118 |
64 |
$19K |
| D1320 |
|
550 |
550 |
$19K |
| D4341 |
|
111 |
43 |
$17K |
| D5226 |
|
25 |
25 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
535 |
535 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
50 |
$6K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
28 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$329.28 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$257.91 |