| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
979 |
484 |
$83K |
| D1120 |
Prophylaxis - child |
1,756 |
1,756 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,848 |
1,848 |
$37K |
| D1110 |
Prophylaxis - adult |
844 |
844 |
$36K |
| D0330 |
Panoramic radiographic image |
611 |
611 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,402 |
1,402 |
$20K |
| D0274 |
Bitewings - four radiographic images |
692 |
692 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
611 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,198 |
1,190 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
173 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,087 |
997 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
380 |
$11K |
| D0272 |
Bitewings - two radiographic images |
412 |
412 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
261 |
256 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
38 |
$6K |
| D1351 |
Sealant - per tooth |
156 |
51 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$169.08 |