| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,195 |
722 |
$89K |
| D1206 |
Topical application of fluoride varnish |
3,847 |
3,729 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,459 |
3,451 |
$76K |
| D1120 |
Prophylaxis - child |
2,832 |
2,830 |
$76K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,709 |
1,456 |
$49K |
| D1110 |
Prophylaxis - adult |
986 |
986 |
$33K |
| D1999 |
|
2,980 |
2,674 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,765 |
2,718 |
$17K |
| D0274 |
Bitewings - four radiographic images |
764 |
763 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,031 |
1,030 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,583 |
2,216 |
$13K |
| D1351 |
Sealant - per tooth |
292 |
96 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
78 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
25 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
15 |
$2K |