| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,163 |
994 |
$187K |
| D1120 |
Prophylaxis - child |
2,932 |
2,925 |
$127K |
| D1206 |
Topical application of fluoride varnish |
3,128 |
3,121 |
$96K |
| D1351 |
Sealant - per tooth |
3,111 |
866 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,887 |
2,882 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
458 |
289 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,696 |
1,694 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,914 |
2,901 |
$26K |
| D0274 |
Bitewings - four radiographic images |
758 |
754 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,760 |
2,748 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
471 |
456 |
$11K |
| D0603 |
|
1,204 |
1,199 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
52 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
28 |
$3K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0601 |
|
73 |
73 |
$730.00 |
| D0602 |
|
64 |
64 |
$640.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$510.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$425.00 |