| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,591 |
942 |
$111K |
| D1110 |
Prophylaxis - adult |
2,112 |
2,108 |
$95K |
| D1206 |
Topical application of fluoride varnish |
2,228 |
2,224 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,169 |
701 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,460 |
2,456 |
$61K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
52 |
$30K |
| D1120 |
Prophylaxis - child |
565 |
565 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,883 |
1,879 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
472 |
472 |
$21K |
| D1351 |
Sealant - per tooth |
928 |
174 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
206 |
159 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,188 |
2,184 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,449 |
2,442 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
415 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
170 |
$8K |
| D0603 |
|
647 |
646 |
$6K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$1K |
| D1353 |
|
84 |
17 |
$840.00 |
| D2950 |
|
12 |
12 |
$660.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
29 |
$325.00 |
| D0601 |
|
13 |
13 |
$130.00 |