| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
808 |
466 |
$79K |
| D1110 |
Prophylaxis - adult |
1,428 |
1,428 |
$71K |
| D1120 |
Prophylaxis - child |
1,272 |
1,272 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,106 |
1,104 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
990 |
990 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,307 |
1,307 |
$35K |
| D0330 |
Panoramic radiographic image |
664 |
664 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
367 |
199 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,373 |
1,373 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,896 |
1,896 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,704 |
1,688 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
632 |
532 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
86 |
$10K |
| D0240 |
|
697 |
354 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
940 |
670 |
$8K |
| D0272 |
Bitewings - two radiographic images |
417 |
417 |
$8K |
| D1351 |
Sealant - per tooth |
181 |
56 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
28 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
12 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$432.00 |