| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,248 |
560 |
$203K |
| D2394 |
|
674 |
345 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
982 |
500 |
$113K |
| D0330 |
Panoramic radiographic image |
829 |
790 |
$41K |
| D1110 |
Prophylaxis - adult |
906 |
868 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,731 |
2,571 |
$41K |
| D7240 |
Removal of impacted tooth - completely bony |
170 |
51 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,010 |
954 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,603 |
1,541 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
222 |
33 |
$27K |
| D0274 |
Bitewings - four radiographic images |
876 |
826 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
763 |
735 |
$23K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
56 |
52 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,035 |
998 |
$21K |
| D1120 |
Prophylaxis - child |
642 |
621 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
156 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,984 |
1,605 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
27 |
$8K |
| D0350 |
|
242 |
229 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
175 |
157 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
30 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$4K |
| D0272 |
Bitewings - two radiographic images |
165 |
165 |
$3K |
| D1351 |
Sealant - per tooth |
95 |
26 |
$2K |
| D1320 |
|
24 |
19 |
$872.76 |