| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
432 |
249 |
$48K |
| D1110 |
Prophylaxis - adult |
780 |
775 |
$45K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
207 |
127 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
968 |
963 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
158 |
101 |
$18K |
| D0274 |
Bitewings - four radiographic images |
451 |
449 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
303 |
$14K |
| D1206 |
Topical application of fluoride varnish |
772 |
767 |
$14K |
| D1120 |
Prophylaxis - child |
312 |
312 |
$14K |
| D0330 |
Panoramic radiographic image |
211 |
211 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
90 |
$11K |
| D1351 |
Sealant - per tooth |
286 |
64 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
377 |
$5K |
| D2332 |
|
32 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
139 |
$2K |
| D9110 |
|
54 |
54 |
$2K |
| D0270 |
|
124 |
121 |
$2K |
| D0603 |
|
195 |
193 |
$1K |
| D1330 |
|
353 |
350 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
26 |
$336.00 |