| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
825 |
573 |
$107K |
| D1110 |
Prophylaxis - adult |
1,657 |
1,607 |
$93K |
| D0274 |
Bitewings - four radiographic images |
2,271 |
2,233 |
$92K |
| D1351 |
Sealant - per tooth |
2,548 |
852 |
$91K |
| D0330 |
Panoramic radiographic image |
1,190 |
1,142 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
820 |
554 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,519 |
2,456 |
$85K |
| D1206 |
Topical application of fluoride varnish |
2,589 |
2,531 |
$64K |
| D1120 |
Prophylaxis - child |
1,443 |
1,412 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,187 |
1,426 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
764 |
735 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,531 |
1,523 |
$28K |
| D0272 |
Bitewings - two radiographic images |
607 |
594 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
183 |
97 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
65 |
$14K |
| D2331 |
|
33 |
29 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
138 |
$3K |
| D1353 |
|
161 |
78 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$675.00 |