| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,138 |
744 |
$150K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,171 |
523 |
$113K |
| D1110 |
Prophylaxis - adult |
1,808 |
1,797 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,710 |
2,703 |
$65K |
| D1120 |
Prophylaxis - child |
1,779 |
1,778 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,358 |
1,350 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,232 |
2,225 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,113 |
1,109 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
884 |
871 |
$30K |
| D0272 |
Bitewings - two radiographic images |
664 |
663 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,134 |
1,124 |
$14K |
| D0330 |
Panoramic radiographic image |
188 |
188 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
24 |
$791.70 |
| D0180 |
|
12 |
12 |
$509.40 |