| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12,695 |
7,867 |
$1.33M |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
8,518 |
5,720 |
$1.08M |
| D1110 |
Prophylaxis - adult |
19,096 |
18,359 |
$696K |
| D0120 |
Periodic oral evaluation - established patient |
24,812 |
24,023 |
$633K |
| D0230 |
Intraoral - periapical each additional radiographic image |
59,378 |
22,003 |
$611K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
11,459 |
10,911 |
$461K |
| D0220 |
Intraoral - periapical first radiographic image |
28,563 |
26,879 |
$415K |
| D1120 |
Prophylaxis - child |
15,047 |
14,531 |
$406K |
| D0274 |
Bitewings - four radiographic images |
13,019 |
12,431 |
$396K |
| D2331 |
|
4,733 |
1,892 |
$371K |
| D1206 |
Topical application of fluoride varnish |
21,092 |
20,361 |
$337K |
| D0330 |
Panoramic radiographic image |
5,926 |
5,632 |
$317K |
| D0140 |
Limited oral evaluation - problem focused |
8,995 |
8,240 |
$308K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,925 |
2,614 |
$307K |
| D1351 |
Sealant - per tooth |
9,846 |
2,585 |
$275K |
| D2394 |
|
1,572 |
1,164 |
$236K |
| D2332 |
|
2,324 |
1,469 |
$216K |
| D0272 |
Bitewings - two radiographic images |
5,922 |
5,697 |
$105K |
| D7240 |
Removal of impacted tooth - completely bony |
596 |
171 |
$101K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
868 |
330 |
$85K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,067 |
364 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,054 |
637 |
$66K |
| D4355 |
|
584 |
553 |
$36K |
| D9110 |
|
787 |
737 |
$30K |
| D9222 |
|
445 |
364 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
555 |
504 |
$24K |
| D9612 |
|
439 |
362 |
$23K |
| D2330 |
|
350 |
220 |
$21K |
| D0240 |
|
1,027 |
587 |
$16K |
| D7530 |
|
120 |
110 |
$13K |
| D7230 |
|
84 |
44 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
73 |
51 |
$10K |
| D2335 |
|
25 |
17 |
$3K |
| D7250 |
|
26 |
12 |
$3K |
| D4341 |
|
25 |
12 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
20 |
12 |
$359.19 |