| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
228 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
209 |
139 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
872 |
843 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
171 |
$19K |
| D1120 |
Prophylaxis - child |
618 |
602 |
$15K |
| D1110 |
Prophylaxis - adult |
429 |
412 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
801 |
771 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
251 |
$10K |
| D1351 |
Sealant - per tooth |
302 |
58 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
222 |
$7K |
| D0274 |
Bitewings - four radiographic images |
246 |
235 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
67 |
26 |
$6K |
| D0330 |
Panoramic radiographic image |
94 |
91 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
328 |
$5K |
| D0272 |
Bitewings - two radiographic images |
237 |
232 |
$4K |
| D4355 |
|
49 |
43 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
153 |
$2K |
| D2394 |
|
16 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D2330 |
|
20 |
14 |
$1K |
| D7111 |
|
19 |
12 |
$730.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$612.75 |