| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
205 |
163 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
165 |
$8K |
| D4910 |
|
251 |
251 |
$8K |
| D1110 |
Prophylaxis - adult |
265 |
265 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
143 |
62 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
437 |
436 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
168 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
116 |
$3K |
| D2331 |
|
73 |
59 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
46 |
$3K |
| D0274 |
Bitewings - four radiographic images |
196 |
195 |
$2K |
| D4342 |
|
52 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
193 |
$2K |
| D4341 |
|
25 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
82 |
$1K |
| D1120 |
Prophylaxis - child |
90 |
89 |
$1K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$1K |
| D1206 |
Topical application of fluoride varnish |
74 |
73 |
$513.00 |
| D0270 |
|
47 |
47 |
$374.00 |
| D0272 |
Bitewings - two radiographic images |
37 |
36 |
$300.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
27 |
$252.00 |
| D1351 |
Sealant - per tooth |
29 |
12 |
$210.00 |