| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,909 |
971 |
$168K |
| D1110 |
Prophylaxis - adult |
2,453 |
2,453 |
$120K |
| D0274 |
Bitewings - four radiographic images |
2,923 |
2,923 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,370 |
2,370 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
565 |
358 |
$38K |
| D0330 |
Panoramic radiographic image |
761 |
761 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,028 |
2,028 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
128 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
521 |
$20K |
| D1120 |
Prophylaxis - child |
567 |
567 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
492 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
926 |
895 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
25 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
158 |
144 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$266.00 |