| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
782 |
782 |
$68K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
328 |
116 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
505 |
501 |
$28K |
| D1110 |
Prophylaxis - adult |
395 |
395 |
$26K |
| D8670 |
Periodic orthodontic treatment visit |
195 |
193 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
850 |
850 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
97 |
94 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
40 |
$5K |
| D1206 |
Topical application of fluoride varnish |
735 |
735 |
$4K |
| D4341 |
|
85 |
25 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
24 |
$3K |
| D9995 |
|
34 |
34 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
241 |
$945.67 |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$445.29 |
| D0274 |
Bitewings - four radiographic images |
23 |
23 |
$170.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
36 |
$0.00 |