| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
71 |
13 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
41 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
48 |
$5K |
| D1206 |
Topical application of fluoride varnish |
230 |
184 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
145 |
$4K |
| D1110 |
Prophylaxis - adult |
109 |
83 |
$4K |
| D1120 |
Prophylaxis - child |
112 |
89 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
93 |
$3K |
| D0330 |
Panoramic radiographic image |
79 |
62 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
169 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
76 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
57 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
19 |
$1K |
| D4346 |
|
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
99 |
$749.07 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$218.73 |