| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,353 |
5,343 |
$335K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,209 |
2,276 |
$279K |
| D0120 |
Periodic oral evaluation - established patient |
4,782 |
4,768 |
$244K |
| D0210 |
Intraoral - complete series of radiographic images |
4,236 |
4,224 |
$198K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,051 |
1,216 |
$162K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,920 |
6,795 |
$147K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,185 |
611 |
$139K |
| D0274 |
Bitewings - four radiographic images |
5,618 |
5,595 |
$117K |
| D8670 |
Periodic orthodontic treatment visit |
385 |
384 |
$107K |
| D1110 |
Prophylaxis - adult |
1,215 |
1,212 |
$96K |
| D1120 |
Prophylaxis - child |
2,552 |
2,544 |
$92K |
| D4341 |
|
1,310 |
484 |
$90K |
| D4910 |
|
847 |
840 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
914 |
570 |
$49K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
122 |
92 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,643 |
2,632 |
$29K |
| D0350 |
|
2,262 |
1,177 |
$21K |
| D1206 |
Topical application of fluoride varnish |
923 |
923 |
$12K |
| D0330 |
Panoramic radiographic image |
626 |
626 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
25 |
24 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
49 |
19 |
$11K |
| D9222 |
|
95 |
93 |
$11K |
| D2394 |
|
120 |
94 |
$10K |
| D4342 |
|
214 |
91 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
121 |
81 |
$8K |
| D9910 |
|
129 |
129 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
180 |
$5K |
| D1351 |
Sealant - per tooth |
208 |
55 |
$5K |
| D2330 |
|
62 |
43 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
15 |
$3K |
| D9430 |
|
77 |
77 |
$2K |
| D2954 |
|
18 |
15 |
$2K |
| D2140 |
|
15 |
13 |
$764.40 |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$570.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$412.00 |
| D0270 |
|
12 |
12 |
$60.00 |
| D1330 |
|
69 |
69 |
$0.00 |