| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
472 |
203 |
$112K |
| D1110 |
Prophylaxis - adult |
645 |
643 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
127 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
516 |
$25K |
| D0330 |
Panoramic radiographic image |
316 |
316 |
$19K |
| D0274 |
Bitewings - four radiographic images |
452 |
452 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
183 |
182 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
47 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
13 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
240 |
236 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
522 |
491 |
$5K |
| D1120 |
Prophylaxis - child |
100 |
98 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
131 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
27 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
520 |
242 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
104 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$860.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$800.00 |
| D0603 |
|
30 |
27 |
$0.00 |