| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,415 |
867 |
$177K |
| D1120 |
Prophylaxis - child |
3,234 |
3,192 |
$144K |
| D1206 |
Topical application of fluoride varnish |
4,045 |
3,988 |
$101K |
| D1351 |
Sealant - per tooth |
2,395 |
568 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,709 |
2,679 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
657 |
638 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,361 |
1,189 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,474 |
1,450 |
$23K |
| D1110 |
Prophylaxis - adult |
289 |
284 |
$19K |
| D3120 |
|
489 |
357 |
$17K |
| D0330 |
Panoramic radiographic image |
341 |
337 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
53 |
$13K |
| D1330 |
|
1,647 |
1,624 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$6K |
| D9248 |
|
29 |
29 |
$5K |
| D0274 |
Bitewings - four radiographic images |
161 |
158 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$1K |
| D0240 |
|
68 |
68 |
$711.00 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$614.64 |