| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
332 |
169 |
$19K |
| D1110 |
Prophylaxis - adult |
350 |
350 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
331 |
328 |
$10K |
| D0330 |
Panoramic radiographic image |
293 |
293 |
$10K |
| D8670 |
Periodic orthodontic treatment visit |
79 |
79 |
$7K |
| D5120 |
|
13 |
13 |
$7K |
| D5110 |
|
13 |
13 |
$6K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
288 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
75 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
264 |
264 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
52 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
89 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
347 |
345 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D0270 |
|
155 |
155 |
$1K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$752.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$704.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
26 |
$272.00 |
| D1330 |
|
87 |
87 |
$55.00 |
| D1310 |
|
41 |
41 |
$10.00 |
| D0603 |
|
20 |
20 |
$0.00 |
| D1999 |
|
89 |
80 |
$0.00 |