| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,951 |
636 |
$231K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,574 |
2,571 |
$161K |
| D0120 |
Periodic oral evaluation - established patient |
3,453 |
3,448 |
$158K |
| D0210 |
Intraoral - complete series of radiographic images |
2,504 |
2,500 |
$118K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,068 |
3,867 |
$73K |
| D1120 |
Prophylaxis - child |
2,267 |
2,262 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,671 |
2,664 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
574 |
301 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,841 |
2,836 |
$29K |
| D1110 |
Prophylaxis - adult |
312 |
312 |
$27K |
| D0330 |
Panoramic radiographic image |
1,099 |
1,090 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
328 |
195 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
142 |
92 |
$11K |
| D2330 |
|
100 |
15 |
$8K |
| D4341 |
|
91 |
26 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
108 |
$4K |
| D0350 |
|
412 |
243 |
$3K |
| D4910 |
|
131 |
127 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
12 |
$3K |
| D9910 |
|
50 |
50 |
$2K |
| D7261 |
|
20 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
149 |
149 |
$2K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$316.00 |
| D1330 |
|
171 |
170 |
$0.00 |
| D4921 |
|
624 |
157 |
$0.00 |