| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,095 |
650 |
$115K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,616 |
3,072 |
$65K |
| D1120 |
Prophylaxis - child |
1,786 |
1,786 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
3,402 |
3,368 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,415 |
2,415 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,900 |
2,899 |
$49K |
| D1110 |
Prophylaxis - adult |
959 |
959 |
$42K |
| D9248 |
|
253 |
250 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,034 |
$30K |
| D0330 |
Panoramic radiographic image |
518 |
518 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
184 |
52 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
284 |
120 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
231 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
86 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
472 |
467 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
454 |
429 |
$12K |
| D1351 |
Sealant - per tooth |
402 |
148 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
37 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
305 |
$8K |
| D0240 |
|
432 |
223 |
$8K |
| D4341 |
|
36 |
12 |
$5K |
| D2331 |
|
21 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$256.20 |