| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,041 |
561 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
975 |
544 |
$46K |
| D1351 |
Sealant - per tooth |
2,677 |
852 |
$45K |
| D1120 |
Prophylaxis - child |
1,957 |
1,919 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,058 |
1,045 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,054 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,865 |
1,831 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,454 |
1,429 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
195 |
193 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
279 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
214 |
$3K |
| D1110 |
Prophylaxis - adult |
113 |
109 |
$3K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
269 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
61 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$808.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$269.00 |