| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,146 |
780 |
$10K |
| D1110 |
Prophylaxis - adult |
1,303 |
1,299 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,572 |
1,566 |
$7K |
| D1120 |
Prophylaxis - child |
1,208 |
1,204 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
672 |
252 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
873 |
558 |
$5K |
| D1206 |
Topical application of fluoride varnish |
2,050 |
2,031 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
893 |
888 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
645 |
645 |
$3K |
| D0274 |
Bitewings - four radiographic images |
593 |
590 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
281 |
$2K |
| D0603 |
|
1,060 |
1,054 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
588 |
584 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
60 |
$1K |
| D4341 |
|
204 |
95 |
$720.00 |
| D0602 |
|
373 |
372 |
$473.00 |
| D0601 |
|
364 |
364 |
$440.00 |
| D0272 |
Bitewings - two radiographic images |
172 |
172 |
$420.00 |
| D4910 |
|
54 |
53 |
$210.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
139 |
$198.00 |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$104.00 |
| D1310 |
|
2,942 |
2,911 |
$80.00 |
| D1330 |
|
2,959 |
2,923 |
$10.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
24 |
$0.00 |
| D9995 |
|
83 |
83 |
$0.00 |