| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
722 |
261 |
$160K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
943 |
349 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
813 |
803 |
$51K |
| D9430 |
|
1,189 |
1,181 |
$38K |
| D0330 |
Panoramic radiographic image |
1,031 |
1,030 |
$31K |
| D7230 |
|
135 |
83 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
384 |
374 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
272 |
272 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
84 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
64 |
$7K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$3K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
471 |
219 |
$2K |
| D1206 |
Topical application of fluoride varnish |
84 |
84 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$935.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$626.40 |