| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,018 |
1,066 |
$138K |
| D1110 |
Prophylaxis - adult |
2,789 |
2,784 |
$122K |
| D1206 |
Topical application of fluoride varnish |
2,975 |
2,970 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,837 |
2,832 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
644 |
366 |
$34K |
| D1120 |
Prophylaxis - child |
657 |
657 |
$29K |
| D0274 |
Bitewings - four radiographic images |
2,193 |
2,188 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
767 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
407 |
406 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
203 |
136 |
$17K |
| D1351 |
Sealant - per tooth |
759 |
138 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,806 |
2,789 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
3,028 |
3,016 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
528 |
526 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
15 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
170 |
$7K |
| D0603 |
|
830 |
828 |
$6K |
| D1353 |
|
215 |
42 |
$2K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$1K |
| D2335 |
|
14 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$795.00 |