| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
654 |
380 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
489 |
301 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
679 |
388 |
$70K |
| D1120 |
Prophylaxis - child |
1,174 |
1,156 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
809 |
781 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
570 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
347 |
$20K |
| D1351 |
Sealant - per tooth |
396 |
130 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
442 |
$12K |
| D1206 |
Topical application of fluoride varnish |
550 |
544 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
383 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
822 |
805 |
$10K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
469 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
146 |
145 |
$5K |
| D0272 |
Bitewings - two radiographic images |
211 |
209 |
$4K |
| D2332 |
|
27 |
12 |
$4K |
| D0190 |
|
111 |
111 |
$2K |
| D3120 |
|
39 |
14 |
$1K |