| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,244 |
583 |
$157K |
| D1120 |
Prophylaxis - child |
2,382 |
2,297 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,724 |
3,583 |
$81K |
| D1110 |
Prophylaxis - adult |
1,469 |
1,400 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,912 |
1,829 |
$50K |
| D0330 |
Panoramic radiographic image |
874 |
835 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,384 |
1,309 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
461 |
143 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,186 |
1,144 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
787 |
754 |
$27K |
| D1351 |
Sealant - per tooth |
901 |
242 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
394 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
98 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
45 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
769 |
696 |
$12K |
| D1354 |
|
235 |
70 |
$5K |
| D1310 |
|
114 |
110 |
$5K |
| D1330 |
|
115 |
111 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
224 |
87 |
$2K |
| D2331 |
|
25 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
54 |
49 |
$2K |
| D9630 |
|
50 |
36 |
$591.08 |
| D0603 |
|
14 |
14 |
$175.18 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$139.10 |