| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,553 |
1,711 |
$441K |
| D0120 |
Periodic oral evaluation - established patient |
5,329 |
5,173 |
$234K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,517 |
3,450 |
$211K |
| D1120 |
Prophylaxis - child |
4,043 |
3,947 |
$141K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,659 |
7,932 |
$136K |
| D0210 |
Intraoral - complete series of radiographic images |
2,483 |
2,472 |
$100K |
| D0274 |
Bitewings - four radiographic images |
5,985 |
5,865 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,408 |
543 |
$85K |
| D1110 |
Prophylaxis - adult |
970 |
951 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,321 |
4,225 |
$62K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
794 |
351 |
$50K |
| D1351 |
Sealant - per tooth |
1,451 |
354 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
482 |
207 |
$25K |
| D4341 |
|
432 |
132 |
$24K |
| D0350 |
|
1,656 |
705 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
165 |
25 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
26 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
175 |
102 |
$12K |
| D2160 |
|
150 |
82 |
$11K |
| D0330 |
Panoramic radiographic image |
607 |
606 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,500 |
2,324 |
$11K |
| D9430 |
|
367 |
363 |
$11K |
| D4910 |
|
120 |
116 |
$8K |
| D1310 |
|
159 |
159 |
$7K |
| D0272 |
Bitewings - two radiographic images |
543 |
542 |
$6K |
| D9993 |
|
85 |
85 |
$4K |
| D7230 |
|
24 |
13 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
12 |
$4K |
| D1320 |
|
191 |
188 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
14 |
14 |
$2K |
| D0603 |
|
122 |
121 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
53 |
$1K |
| D9248 |
|
14 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$840.00 |
| D9310 |
|
16 |
16 |
$800.00 |
| D0270 |
|
51 |
51 |
$176.50 |
| D1330 |
|
20 |
19 |
$0.00 |