| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
771 |
513 |
$97K |
| D1351 |
Sealant - per tooth |
2,724 |
843 |
$91K |
| D1120 |
Prophylaxis - child |
1,860 |
1,856 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,004 |
2,000 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,486 |
1,555 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
595 |
423 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,506 |
2,500 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,512 |
1,508 |
$55K |
| D0330 |
Panoramic radiographic image |
760 |
759 |
$51K |
| D1110 |
Prophylaxis - adult |
854 |
852 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
1,829 |
1,812 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
628 |
$28K |
| D0272 |
Bitewings - two radiographic images |
694 |
693 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
453 |
428 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
295 |
157 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
237 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
24 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$2K |