| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,026 |
1,046 |
$136K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,864 |
1,864 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
1,557 |
1,543 |
$113K |
| D1120 |
Prophylaxis - child |
1,576 |
1,562 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,248 |
636 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,431 |
1,430 |
$67K |
| D1110 |
Prophylaxis - adult |
529 |
529 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
293 |
195 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,741 |
1,725 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,037 |
1,035 |
$21K |
| D0350 |
|
2,271 |
974 |
$20K |
| D1351 |
Sealant - per tooth |
730 |
214 |
$19K |
| D7240 |
Removal of impacted tooth - completely bony |
65 |
25 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
30 |
27 |
$14K |
| D4910 |
|
132 |
132 |
$10K |
| D1206 |
Topical application of fluoride varnish |
520 |
519 |
$8K |
| D9430 |
|
247 |
236 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
495 |
154 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$480.00 |