| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
913 |
913 |
$90K |
| D1110 |
Prophylaxis - adult |
1,027 |
1,026 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,236 |
695 |
$66K |
| D1120 |
Prophylaxis - child |
799 |
799 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
193 |
136 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
254 |
147 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
662 |
652 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
208 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,014 |
1,014 |
$7K |
| D1351 |
Sealant - per tooth |
1,180 |
247 |
$3K |
| D0274 |
Bitewings - four radiographic images |
533 |
533 |
$2K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$945.66 |
| D0120 |
Periodic oral evaluation - established patient |
1,150 |
1,150 |
$922.22 |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
17 |
$481.87 |
| D2331 |
|
18 |
13 |
$262.17 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
509 |
$209.03 |
| D1206 |
Topical application of fluoride varnish |
1,276 |
1,276 |
$123.89 |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
106 |
$54.20 |
| D0272 |
Bitewings - two radiographic images |
520 |
520 |
$15.87 |
| D0220 |
Intraoral - periapical first radiographic image |
1,806 |
1,783 |
$9.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,579 |
1,184 |
$-154.67 |