| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
268 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
680 |
679 |
$26K |
| D1120 |
Prophylaxis - child |
828 |
826 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
146 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,066 |
855 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
165 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
707 |
703 |
$8K |
| D9993 |
|
124 |
124 |
$7K |
| D0274 |
Bitewings - four radiographic images |
279 |
279 |
$6K |
| D1310 |
|
123 |
123 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
312 |
$4K |
| D9430 |
|
112 |
109 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
40 |
$3K |
| D0272 |
Bitewings - two radiographic images |
117 |
116 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
105 |
105 |
$953.50 |
| D1351 |
Sealant - per tooth |
42 |
12 |
$836.00 |
| D0603 |
|
35 |
35 |
$525.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$520.00 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$275.00 |
| D0602 |
|
12 |
12 |
$180.00 |
| D0350 |
|
19 |
13 |
$157.20 |