| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,300 |
720 |
$173K |
| D0120 |
Periodic oral evaluation - established patient |
2,953 |
2,882 |
$74K |
| D1110 |
Prophylaxis - adult |
1,418 |
1,375 |
$71K |
| D1120 |
Prophylaxis - child |
1,808 |
1,769 |
$67K |
| D2740 |
Crown - porcelain/ceramic |
56 |
53 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,855 |
1,820 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
420 |
301 |
$31K |
| D0274 |
Bitewings - four radiographic images |
776 |
757 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,275 |
1,235 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
564 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
55 |
$13K |
| D0272 |
Bitewings - two radiographic images |
523 |
515 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
330 |
313 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
27 |
$5K |
| D0240 |
|
122 |
62 |
$3K |
| D1351 |
Sealant - per tooth |
84 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
127 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
39 |
$1K |
| D4910 |
|
12 |
12 |
$780.56 |
| D0600 |
|
15 |
15 |
$0.00 |