| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,214 |
617 |
$138K |
| D1120 |
Prophylaxis - child |
3,303 |
3,263 |
$132K |
| D1206 |
Topical application of fluoride varnish |
4,293 |
4,243 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
3,305 |
3,267 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
854 |
431 |
$74K |
| D0274 |
Bitewings - four radiographic images |
1,782 |
1,768 |
$67K |
| D1110 |
Prophylaxis - adult |
1,194 |
1,182 |
$65K |
| D1351 |
Sealant - per tooth |
2,150 |
438 |
$63K |
| D0272 |
Bitewings - two radiographic images |
1,629 |
1,606 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
882 |
882 |
$45K |
| D1354 |
|
2,662 |
791 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
289 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,781 |
1,744 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,110 |
1,087 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
659 |
625 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
331 |
$20K |
| D0330 |
Panoramic radiographic image |
121 |
121 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
26 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$6K |
| D0603 |
|
610 |
610 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$2K |
| D2140 |
|
18 |
14 |
$1K |
| D0602 |
|
75 |
75 |
$367.90 |