| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
423 |
246 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
543 |
543 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
621 |
621 |
$14K |
| D1110 |
Prophylaxis - adult |
557 |
557 |
$13K |
| D1120 |
Prophylaxis - child |
691 |
691 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,061 |
1,061 |
$13K |
| D0330 |
Panoramic radiographic image |
440 |
440 |
$11K |
| D0274 |
Bitewings - four radiographic images |
674 |
674 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,075 |
1,053 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
949 |
690 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
335 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
57 |
$7K |
| D0350 |
|
332 |
324 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
16 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
31 |
$4K |
| D0272 |
Bitewings - two radiographic images |
244 |
244 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$2K |
| D9996 |
|
172 |
171 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$944.00 |
| D1351 |
Sealant - per tooth |
57 |
12 |
$798.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
21 |
$482.00 |