| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
560 |
396 |
$84K |
| D1120 |
Prophylaxis - child |
1,378 |
1,320 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,897 |
1,824 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,513 |
1,461 |
$52K |
| D1110 |
Prophylaxis - adult |
591 |
575 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,155 |
1,106 |
$40K |
| D0330 |
Panoramic radiographic image |
377 |
367 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
281 |
216 |
$34K |
| D0274 |
Bitewings - four radiographic images |
575 |
560 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
324 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
277 |
264 |
$17K |
| D1351 |
Sealant - per tooth |
336 |
106 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
286 |
256 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
529 |
511 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
69 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
13 |
$702.00 |