| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
4,754 |
1,827 |
$699K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
391 |
368 |
$321K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,951 |
2,923 |
$196K |
| D0330 |
Panoramic radiographic image |
3,878 |
3,858 |
$172K |
| D7240 |
Removal of impacted tooth - completely bony |
467 |
198 |
$115K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,246 |
2,133 |
$81K |
| D8670 |
Periodic orthodontic treatment visit |
437 |
424 |
$69K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
229 |
158 |
$59K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
342 |
65 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
670 |
220 |
$54K |
| D9430 |
|
1,496 |
1,496 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
2,632 |
2,293 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,793 |
1,840 |
$33K |
| D7230 |
|
147 |
89 |
$33K |
| D1120 |
Prophylaxis - child |
569 |
569 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
244 |
$28K |
| D9310 |
|
580 |
571 |
$26K |
| D9222 |
|
164 |
164 |
$23K |
| D9420 |
|
136 |
136 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
160 |
160 |
$12K |
| D1206 |
Topical application of fluoride varnish |
462 |
462 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
60 |
$5K |
| D7310 |
|
24 |
14 |
$3K |
| D1310 |
|
60 |
60 |
$3K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$2K |
| D9610 |
|
68 |
28 |
$2K |
| D1354 |
|
145 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
122 |
122 |
$1K |
| D1351 |
Sealant - per tooth |
25 |
13 |
$962.50 |
| D1352 |
|
24 |
13 |
$924.00 |
| D8660 |
|
36 |
36 |
$900.00 |
| D0603 |
|
59 |
59 |
$870.00 |
| D0350 |
|
83 |
40 |
$796.80 |
| D4921 |
|
530 |
221 |
$760.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$455.00 |
| D1999 |
|
36 |
36 |
$360.00 |
| D0470 |
|
30 |
30 |
$335.00 |