| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
648 |
213 |
$218K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,386 |
1,389 |
$180K |
| D1110 |
Prophylaxis - adult |
2,454 |
2,422 |
$171K |
| D1120 |
Prophylaxis - child |
1,790 |
1,762 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,543 |
3,489 |
$68K |
| D2740 |
Crown - porcelain/ceramic |
119 |
83 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
821 |
811 |
$30K |
| D0274 |
Bitewings - four radiographic images |
4,111 |
4,049 |
$21K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
309 |
264 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
665 |
643 |
$18K |
| D9310 |
|
257 |
256 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
222 |
125 |
$12K |
| D1206 |
Topical application of fluoride varnish |
3,688 |
3,629 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
603 |
432 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
5,011 |
4,862 |
$6K |
| D1351 |
Sealant - per tooth |
558 |
158 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,522 |
4,375 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
68 |
37 |
$3K |
| D1330 |
|
4,206 |
4,139 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
76 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
480 |
434 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
445 |
444 |
$1K |
| D2332 |
|
25 |
14 |
$933.66 |
| D9222 |
|
276 |
268 |
$335.36 |
| D1999 |
|
66 |
57 |
$49.05 |
| D4921 |
|
36 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$0.00 |
| D7921 |
|
28 |
27 |
$0.00 |
| D4211 |
|
39 |
25 |
$0.00 |