| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,255 |
724 |
$148K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,850 |
1,847 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
1,931 |
1,919 |
$77K |
| D1110 |
Prophylaxis - adult |
893 |
892 |
$75K |
| D4341 |
|
978 |
258 |
$67K |
| D9430 |
|
1,532 |
1,468 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
906 |
906 |
$42K |
| D1120 |
Prophylaxis - child |
1,359 |
1,357 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,574 |
1,573 |
$33K |
| D4910 |
|
388 |
388 |
$30K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
60 |
51 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,636 |
2,473 |
$26K |
| D0330 |
Panoramic radiographic image |
872 |
867 |
$25K |
| D7240 |
Removal of impacted tooth - completely bony |
84 |
44 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,699 |
1,697 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,121 |
1,097 |
$13K |
| D1206 |
Topical application of fluoride varnish |
616 |
612 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
158 |
92 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
74 |
$8K |
| D2160 |
|
71 |
51 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
25 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D1351 |
Sealant - per tooth |
93 |
27 |
$2K |
| D2931 |
|
16 |
12 |
$2K |
| D2952 |
|
18 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$280.00 |
| D0270 |
|
16 |
16 |
$80.00 |