| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,333 |
656 |
$86K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
126 |
115 |
$61K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
99 |
73 |
$55K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
582 |
224 |
$39K |
| D1110 |
Prophylaxis - adult |
1,112 |
1,075 |
$39K |
| D8670 |
Periodic orthodontic treatment visit |
240 |
240 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
327 |
$26K |
| D1351 |
Sealant - per tooth |
953 |
163 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
453 |
310 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
828 |
704 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
481 |
471 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,094 |
1,046 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
843 |
822 |
$17K |
| D0330 |
Panoramic radiographic image |
455 |
448 |
$17K |
| D0274 |
Bitewings - four radiographic images |
575 |
552 |
$16K |
| D9222 |
|
78 |
73 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,201 |
1,160 |
$10K |
| D1206 |
Topical application of fluoride varnish |
489 |
458 |
$9K |
| D1120 |
Prophylaxis - child |
292 |
278 |
$9K |
| D2331 |
|
119 |
83 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
89 |
$7K |
| D7240 |
Removal of impacted tooth - completely bony |
27 |
12 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
82 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
414 |
221 |
$3K |
| D2330 |
|
63 |
53 |
$3K |
| D0272 |
Bitewings - two radiographic images |
184 |
175 |
$3K |
| D2335 |
|
37 |
28 |
$2K |
| D2332 |
|
35 |
29 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
14 |
$814.00 |
| D1354 |
|
77 |
22 |
$290.00 |
| D9995 |
|
192 |
180 |
$5.14 |