| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,027 |
1,224 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,328 |
1,253 |
$17K |
| D1120 |
Prophylaxis - child |
5,340 |
5,309 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
5,966 |
5,939 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,516 |
6,481 |
$10K |
| D0272 |
Bitewings - two radiographic images |
4,576 |
4,546 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
6,612 |
6,558 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,051 |
6,191 |
$7K |
| D1351 |
Sealant - per tooth |
2,292 |
870 |
$7K |
| D1110 |
Prophylaxis - adult |
1,055 |
1,051 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,134 |
1,933 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
498 |
494 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
546 |
373 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,038 |
1,034 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
119 |
84 |
$2K |
| D7111 |
|
188 |
96 |
$617.17 |
| D0140 |
Limited oral evaluation - problem focused |
169 |
165 |
$601.16 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
12 |
$121.94 |
| D1353 |
|
363 |
123 |
$23.25 |
| D0601 |
|
15 |
15 |
$0.00 |