| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,490 |
785 |
$142K |
| D1110 |
Prophylaxis - adult |
1,346 |
1,340 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
428 |
255 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,433 |
2,416 |
$39K |
| D1120 |
Prophylaxis - child |
1,283 |
1,262 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
1,937 |
1,756 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
479 |
342 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,247 |
1,225 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
866 |
847 |
$26K |
| D0274 |
Bitewings - four radiographic images |
786 |
780 |
$23K |
| D0330 |
Panoramic radiographic image |
354 |
354 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,174 |
958 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
463 |
$14K |
| D0272 |
Bitewings - two radiographic images |
502 |
502 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
309 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
108 |
95 |
$3K |
| D1351 |
Sealant - per tooth |
113 |
41 |
$2K |
| D0350 |
|
19 |
19 |
$579.50 |
| D0603 |
|
41 |
38 |
$375.15 |
| D0602 |
|
28 |
19 |
$256.20 |