| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,641 |
965 |
$204K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,296 |
815 |
$126K |
| D1120 |
Prophylaxis - child |
2,997 |
2,909 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,459 |
3,368 |
$115K |
| D1206 |
Topical application of fluoride varnish |
4,346 |
4,222 |
$104K |
| D0274 |
Bitewings - four radiographic images |
2,449 |
2,399 |
$92K |
| D1110 |
Prophylaxis - adult |
1,652 |
1,605 |
$86K |
| D1351 |
Sealant - per tooth |
2,522 |
916 |
$83K |
| D0330 |
Panoramic radiographic image |
1,092 |
1,069 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
952 |
926 |
$47K |
| D0272 |
Bitewings - two radiographic images |
1,306 |
1,271 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
476 |
293 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,493 |
985 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
172 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,486 |
1,455 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
450 |
444 |
$22K |
| D2140 |
|
172 |
85 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
315 |
264 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
131 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$744.00 |