| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
610 |
336 |
$107K |
| D1120 |
Prophylaxis - child |
1,957 |
1,950 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,922 |
1,915 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,830 |
1,823 |
$56K |
| D0277 |
|
760 |
757 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
794 |
751 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
75 |
$13K |
| D0603 |
|
1,540 |
1,535 |
$10K |
| D0240 |
|
204 |
110 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
24 |
$6K |
| D0602 |
|
658 |
657 |
$4K |
| D0251 |
|
46 |
46 |
$3K |
| D1351 |
Sealant - per tooth |
40 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$945.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$840.00 |
| D1310 |
|
129 |
128 |
$115.00 |
| D1330 |
|
130 |
129 |
$26.25 |