| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,148 |
806 |
$141K |
| D1110 |
Prophylaxis - adult |
2,802 |
2,703 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
5,042 |
4,896 |
$120K |
| D1206 |
Topical application of fluoride varnish |
5,910 |
5,701 |
$103K |
| D1120 |
Prophylaxis - child |
3,158 |
3,040 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
712 |
457 |
$59K |
| D0330 |
Panoramic radiographic image |
848 |
822 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
908 |
850 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
685 |
647 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,083 |
1,048 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
205 |
104 |
$20K |
| D0272 |
Bitewings - two radiographic images |
716 |
695 |
$16K |
| D1351 |
Sealant - per tooth |
444 |
53 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
522 |
485 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$5K |
| D1330 |
|
178 |
164 |
$3K |
| D9920 |
|
47 |
42 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
32 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$2K |
| D4346 |
|
12 |
12 |
$906.00 |