| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
976 |
265 |
$58K |
| D5110 |
|
158 |
152 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,612 |
353 |
$48K |
| D5120 |
|
78 |
73 |
$28K |
| D1110 |
Prophylaxis - adult |
864 |
845 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
483 |
279 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
641 |
629 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
731 |
$15K |
| D0330 |
Panoramic radiographic image |
749 |
733 |
$15K |
| D4341 |
|
614 |
227 |
$14K |
| D2140 |
|
403 |
232 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,024 |
1,010 |
$13K |
| D0274 |
Bitewings - four radiographic images |
933 |
918 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
440 |
417 |
$8K |
| D4910 |
|
171 |
170 |
$7K |
| D2330 |
|
217 |
107 |
$7K |
| D2160 |
|
97 |
72 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
686 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
181 |
180 |
$2K |
| D2331 |
|
30 |
17 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$520.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
310 |
179 |
$429.21 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$275.76 |