| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
656 |
438 |
$100K |
| D1120 |
Prophylaxis - child |
1,469 |
1,441 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,077 |
2,041 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
573 |
392 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,739 |
1,712 |
$60K |
| D1110 |
Prophylaxis - adult |
657 |
647 |
$49K |
| D0330 |
Panoramic radiographic image |
368 |
361 |
$36K |
| D0272 |
Bitewings - two radiographic images |
742 |
728 |
$25K |
| D0274 |
Bitewings - four radiographic images |
525 |
516 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
305 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
59 |
$17K |
| D1351 |
Sealant - per tooth |
283 |
98 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
159 |
154 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
381 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$798.00 |