| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,434 |
1,393 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
990 |
331 |
$179K |
| D4342 |
|
2,093 |
796 |
$123K |
| D7970 |
|
765 |
747 |
$75K |
| D9248 |
|
1,224 |
1,171 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,117 |
2,054 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
508 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
348 |
332 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
52 |
$19K |
| D9243 |
|
56 |
55 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
774 |
748 |
$6K |
| D1351 |
Sealant - per tooth |
170 |
41 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
530 |
170 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,335 |
1,163 |
$3K |
| D9420 |
|
95 |
92 |
$2K |
| D0274 |
Bitewings - four radiographic images |
716 |
701 |
$2K |
| D9239 |
|
37 |
36 |
$1K |
| J7050 |
Infusion, normal saline solution, 250 cc |
55 |
54 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,270 |
1,238 |
$909.75 |
| D7310 |
|
20 |
13 |
$900.00 |
| D1206 |
Topical application of fluoride varnish |
2,208 |
2,145 |
$447.00 |
| J7060 |
5% dextrose/water (500 ml = 1 unit) |
54 |
53 |
$420.00 |
| J3360 |
Injection, diazepam, up to 5 mg |
55 |
54 |
$216.30 |
| D0411 |
|
22 |
20 |
$160.00 |
| J1100 |
Injection, dexamethasone sodium phosphate, 1 mg |
56 |
54 |
$140.00 |
| J2410 |
Injection, oxymorphone hcl, up to 1 mg |
55 |
54 |
$92.75 |
| D1330 |
|
2,209 |
2,146 |
$15.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
13 |
$0.00 |