| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
5,941 |
2,939 |
$585K |
| D8670 |
Periodic orthodontic treatment visit |
2,058 |
2,054 |
$488K |
| D1110 |
Prophylaxis - adult |
6,747 |
6,747 |
$282K |
| D9243 |
|
1,556 |
1,539 |
$251K |
| D0120 |
Periodic oral evaluation - established patient |
8,600 |
8,600 |
$198K |
| D0330 |
Panoramic radiographic image |
5,429 |
5,425 |
$174K |
| D7240 |
Removal of impacted tooth - completely bony |
420 |
236 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,029 |
1,142 |
$139K |
| D0274 |
Bitewings - four radiographic images |
5,069 |
5,069 |
$112K |
| D0340 |
|
2,402 |
2,402 |
$104K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,962 |
7,962 |
$98K |
| D9239 |
|
1,487 |
1,479 |
$93K |
| D0160 |
|
2,579 |
2,579 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
8,760 |
8,753 |
$79K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,438 |
879 |
$76K |
| D8660 |
|
2,576 |
2,574 |
$73K |
| D9310 |
|
1,623 |
1,623 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,027 |
624 |
$52K |
| D0350 |
|
2,798 |
2,796 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
2,453 |
2,450 |
$30K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
42 |
$28K |
| D7230 |
|
111 |
83 |
$22K |
| D1120 |
Prophylaxis - child |
498 |
498 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
317 |
110 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
922 |
$11K |
| D2394 |
|
104 |
83 |
$10K |
| D2331 |
|
157 |
69 |
$10K |
| D2954 |
|
45 |
38 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
498 |
496 |
$6K |
| D1206 |
Topical application of fluoride varnish |
185 |
185 |
$5K |
| D2332 |
|
155 |
51 |
$4K |
| D1351 |
Sealant - per tooth |
74 |
24 |
$3K |