| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,219 |
669 |
$59K |
| D1110 |
Prophylaxis - adult |
1,447 |
1,433 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,628 |
1,619 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
919 |
300 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,364 |
1,347 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
511 |
335 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
615 |
589 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
478 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
350 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,108 |
1,098 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
134 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,088 |
1,044 |
$8K |
| D0330 |
Panoramic radiographic image |
316 |
313 |
$7K |
| D4910 |
|
130 |
130 |
$6K |
| D2331 |
|
148 |
81 |
$6K |
| D1999 |
|
737 |
624 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
75 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
342 |
342 |
$4K |
| D4341 |
|
71 |
30 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
528 |
304 |
$760.95 |
| D2330 |
|
24 |
12 |
$670.11 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$643.44 |
| D0272 |
Bitewings - two radiographic images |
51 |
50 |
$447.65 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$280.00 |