| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,913 |
1,121 |
$204K |
| D1110 |
Prophylaxis - adult |
3,950 |
3,950 |
$201K |
| D0120 |
Periodic oral evaluation - established patient |
4,594 |
4,593 |
$108K |
| D1206 |
Topical application of fluoride varnish |
5,543 |
5,542 |
$92K |
| D0274 |
Bitewings - four radiographic images |
3,111 |
3,111 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
440 |
340 |
$59K |
| D1120 |
Prophylaxis - child |
1,577 |
1,576 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
372 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,090 |
1,090 |
$45K |
| D0330 |
Panoramic radiographic image |
838 |
838 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
397 |
387 |
$13K |
| D1351 |
Sealant - per tooth |
203 |
58 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
36 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
419 |
417 |
$5K |
| D0272 |
Bitewings - two radiographic images |
250 |
250 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$1K |