| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,330 |
607 |
$135K |
| D1120 |
Prophylaxis - child |
1,868 |
1,843 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,207 |
2,154 |
$44K |
| D0330 |
Panoramic radiographic image |
855 |
842 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,409 |
2,356 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,142 |
1,110 |
$33K |
| D1110 |
Prophylaxis - adult |
764 |
727 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,075 |
1,052 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,286 |
1,286 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,184 |
1,834 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
68 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
100 |
28 |
$12K |
| D1206 |
Topical application of fluoride varnish |
665 |
623 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
42 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
107 |
$3K |
| D1351 |
Sealant - per tooth |
96 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
122 |
119 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
26 |
$740.88 |