| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
65 |
65 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
1,456 |
1,394 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,280 |
578 |
$17K |
| D0330 |
Panoramic radiographic image |
815 |
784 |
$16K |
| D7240 |
Removal of impacted tooth - completely bony |
56 |
30 |
$10K |
| D7230 |
|
45 |
28 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
19 |
$4K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
743 |
686 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
351 |
329 |
$1K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$997.92 |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$926.90 |
| D1351 |
Sealant - per tooth |
27 |
12 |
$871.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$594.89 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$566.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$415.80 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$282.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
19 |
$223.60 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$110.40 |
| D7140 |
Extraction, erupted tooth or exposed root |
124 |
52 |
$0.00 |
| D1999 |
|
743 |
637 |
$0.00 |