| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,550 |
505 |
$152K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,941 |
592 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,045 |
4,011 |
$84K |
| D1110 |
Prophylaxis - adult |
1,754 |
1,737 |
$78K |
| D1120 |
Prophylaxis - child |
2,263 |
2,249 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,085 |
4,053 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,249 |
2,121 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
3,198 |
3,076 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,270 |
2,252 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,125 |
2,569 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
43 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$348.60 |