| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
605 |
269 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
638 |
233 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
656 |
548 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
694 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
197 |
116 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
87 |
42 |
$17K |
| D1351 |
Sealant - per tooth |
216 |
29 |
$6K |
| D4346 |
|
44 |
42 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
106 |
$4K |
| D1110 |
Prophylaxis - adult |
72 |
69 |
$4K |
| D0330 |
Panoramic radiographic image |
76 |
71 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
200 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
52 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
77 |
$567.08 |
| D1120 |
Prophylaxis - child |
13 |
12 |
$414.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$323.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$280.39 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$278.55 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$235.68 |