| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,482 |
713 |
$123K |
| D1110 |
Prophylaxis - adult |
729 |
729 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
696 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
124 |
$15K |
| D0274 |
Bitewings - four radiographic images |
408 |
408 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
73 |
$9K |
| D0330 |
Panoramic radiographic image |
272 |
272 |
$9K |
| D1120 |
Prophylaxis - child |
141 |
141 |
$6K |
| D2394 |
|
42 |
27 |
$6K |
| D8670 |
Periodic orthodontic treatment visit |
15 |
15 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D2335 |
|
27 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
42 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
202 |
$3K |
| D2332 |
|
23 |
18 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
17 |
$2K |
| D4341 |
|
34 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
156 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
112 |
$1K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$988.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$90.75 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
48 |
$0.00 |
| D1999 |
|
29 |
29 |
$0.00 |