| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,567 |
1,471 |
$176K |
| D1110 |
Prophylaxis - adult |
4,062 |
3,923 |
$168K |
| D1206 |
Topical application of fluoride varnish |
6,316 |
6,113 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
4,741 |
4,607 |
$113K |
| D1120 |
Prophylaxis - child |
2,694 |
2,632 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,418 |
992 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,437 |
2,367 |
$59K |
| D0330 |
Panoramic radiographic image |
1,415 |
1,369 |
$56K |
| D1351 |
Sealant - per tooth |
1,716 |
749 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
525 |
380 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,206 |
1,184 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,462 |
1,390 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
549 |
508 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,183 |
601 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
49 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$536.80 |