| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,469 |
849 |
$106K |
| D1120 |
Prophylaxis - child |
2,425 |
2,221 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,526 |
3,196 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,286 |
2,046 |
$54K |
| D1110 |
Prophylaxis - adult |
925 |
822 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,129 |
1,059 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,311 |
1,177 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,288 |
1,195 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
385 |
209 |
$24K |
| D1351 |
Sealant - per tooth |
893 |
265 |
$19K |
| D0330 |
Panoramic radiographic image |
442 |
384 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,119 |
998 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
541 |
413 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
338 |
288 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
636 |
524 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
177 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
16 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$666.83 |
| D0270 |
|
18 |
16 |
$163.68 |