| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
414 |
300 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
168 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
686 |
$18K |
| D1110 |
Prophylaxis - adult |
207 |
203 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
187 |
101 |
$10K |
| D1120 |
Prophylaxis - child |
226 |
224 |
$9K |
| D1206 |
Topical application of fluoride varnish |
355 |
349 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
85 |
83 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
292 |
288 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
123 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
86 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0240 |
|
57 |
48 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
42 |
$860.00 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$530.00 |
| D0270 |
|
12 |
12 |
$110.00 |