| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,240 |
602 |
$97K |
| D0140 |
Limited oral evaluation - problem focused |
1,933 |
1,827 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
473 |
344 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
933 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
530 |
352 |
$48K |
| D0330 |
Panoramic radiographic image |
738 |
700 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
200 |
82 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,334 |
1,273 |
$36K |
| D1120 |
Prophylaxis - child |
820 |
804 |
$32K |
| D1110 |
Prophylaxis - adult |
547 |
524 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,729 |
1,591 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
538 |
487 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
654 |
631 |
$14K |
| D0274 |
Bitewings - four radiographic images |
386 |
379 |
$12K |
| D1206 |
Topical application of fluoride varnish |
411 |
401 |
$10K |
| D4341 |
|
81 |
37 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
128 |
$8K |
| D0272 |
Bitewings - two radiographic images |
209 |
204 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
224 |
151 |
$3K |
| D0191 |
|
91 |
85 |
$2K |
| D4910 |
|
13 |
13 |
$812.00 |
| D0180 |
|
15 |
14 |
$690.60 |
| D0350 |
|
13 |
13 |
$518.50 |
| D8670 |
Periodic orthodontic treatment visit |
179 |
153 |
$0.00 |