| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,076 |
369 |
$105K |
| D1120 |
Prophylaxis - child |
2,103 |
1,991 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,358 |
1,268 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
714 |
263 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,022 |
1,913 |
$53K |
| D1351 |
Sealant - per tooth |
1,243 |
323 |
$45K |
| D0330 |
Panoramic radiographic image |
585 |
544 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
328 |
187 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
520 |
460 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
717 |
693 |
$23K |
| D0272 |
Bitewings - two radiographic images |
520 |
492 |
$15K |
| D0274 |
Bitewings - four radiographic images |
241 |
221 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
164 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
183 |
$3K |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
24 |
$683.06 |