| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
969 |
969 |
$273K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,977 |
3,977 |
$239K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,511 |
1,772 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
4,226 |
4,223 |
$169K |
| D9221 |
|
755 |
628 |
$160K |
| D0210 |
Intraoral - complete series of radiographic images |
3,303 |
3,295 |
$152K |
| D9220 |
|
628 |
628 |
$134K |
| D1120 |
Prophylaxis - child |
4,006 |
4,000 |
$120K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
377 |
305 |
$117K |
| D1110 |
Prophylaxis - adult |
943 |
942 |
$77K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
545 |
269 |
$43K |
| D0274 |
Bitewings - four radiographic images |
2,108 |
2,104 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,776 |
4,990 |
$42K |
| D9222 |
|
307 |
306 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
307 |
136 |
$37K |
| D4341 |
|
508 |
172 |
$34K |
| D7240 |
Removal of impacted tooth - completely bony |
137 |
52 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
748 |
748 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
440 |
284 |
$24K |
| D7230 |
|
105 |
67 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,855 |
1,848 |
$18K |
| D0272 |
Bitewings - two radiographic images |
821 |
821 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
26 |
$4K |
| D1351 |
Sealant - per tooth |
124 |
31 |
$3K |
| D2394 |
|
22 |
12 |
$2K |
| D9993 |
|
13 |
13 |
$845.00 |
| D1310 |
|
13 |
13 |
$598.00 |
| D0270 |
|
12 |
12 |
$60.00 |