| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
57 |
25 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
110 |
$13K |
| D9310 |
|
175 |
174 |
$11K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$7K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
42 |
$5K |
| D9243 |
|
25 |
25 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
32 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
93 |
32 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
42 |
42 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
39 |
$3K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$1K |
| D9239 |
|
12 |
12 |
$817.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$165.30 |