| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
839 |
475 |
$95K |
| D1110 |
Prophylaxis - adult |
1,080 |
1,074 |
$63K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
419 |
266 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
278 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,131 |
1,123 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
130 |
93 |
$22K |
| D0274 |
Bitewings - four radiographic images |
555 |
550 |
$21K |
| D0330 |
Panoramic radiographic image |
276 |
276 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
297 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
191 |
189 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
19 |
13 |
$14K |
| D1206 |
Topical application of fluoride varnish |
716 |
713 |
$11K |
| D2332 |
|
87 |
58 |
$11K |
| D1120 |
Prophylaxis - child |
226 |
226 |
$10K |
| D2394 |
|
73 |
45 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
667 |
657 |
$8K |
| D9110 |
|
231 |
231 |
$7K |
| D0270 |
|
292 |
291 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
196 |
$3K |
| D0272 |
Bitewings - two radiographic images |
96 |
96 |
$3K |
| D0603 |
|
382 |
375 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
13 |
$2K |
| D1330 |
|
654 |
645 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
144 |
$2K |
| D0602 |
|
133 |
133 |
$900.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$420.00 |
| D1999 |
|
17 |
16 |
$0.00 |