| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,536 |
767 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,361 |
516 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
619 |
412 |
$39K |
| D1110 |
Prophylaxis - adult |
668 |
660 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
742 |
$21K |
| D0330 |
Panoramic radiographic image |
699 |
687 |
$18K |
| D2332 |
|
261 |
150 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
733 |
685 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,074 |
1,059 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
504 |
499 |
$10K |
| D1120 |
Prophylaxis - child |
471 |
469 |
$10K |
| D0240 |
|
862 |
431 |
$7K |
| D0274 |
Bitewings - four radiographic images |
686 |
673 |
$7K |
| D9110 |
|
149 |
141 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
711 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
51 |
$4K |
| D0272 |
Bitewings - two radiographic images |
393 |
390 |
$4K |
| D4341 |
|
103 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
111 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$956.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
559 |
470 |
$793.14 |
| D1351 |
Sealant - per tooth |
42 |
13 |
$791.28 |