| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
777 |
317 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
526 |
213 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,387 |
922 |
$37K |
| D0330 |
Panoramic radiographic image |
1,319 |
859 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
2,420 |
1,240 |
$30K |
| D1110 |
Prophylaxis - adult |
1,408 |
785 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,780 |
1,029 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,910 |
830 |
$21K |
| D1206 |
Topical application of fluoride varnish |
2,857 |
1,550 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,009 |
1,219 |
$17K |
| D1120 |
Prophylaxis - child |
1,283 |
612 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
108 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
173 |
71 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
594 |
336 |
$11K |
| D1351 |
Sealant - per tooth |
226 |
46 |
$6K |
| D4346 |
|
50 |
47 |
$2K |
| D0272 |
Bitewings - two radiographic images |
161 |
68 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
44 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
14 |
$629.16 |
| D0270 |
|
14 |
13 |
$59.35 |
| D0350 |
|
2,275 |
942 |
$18.86 |
| D0431 |
|
33 |
31 |
$0.00 |
| D4921 |
|
467 |
121 |
$0.00 |
| D0351 |
|
211 |
65 |
$0.00 |
| D0801 |
|
628 |
481 |
$0.00 |