| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
369 |
160 |
$35K |
| D1120 |
Prophylaxis - child |
1,114 |
1,059 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
780 |
714 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
664 |
569 |
$23K |
| D0274 |
Bitewings - four radiographic images |
715 |
642 |
$18K |
| D0330 |
Panoramic radiographic image |
346 |
328 |
$17K |
| D1206 |
Topical application of fluoride varnish |
733 |
701 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
225 |
101 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
79 |
$12K |
| D1351 |
Sealant - per tooth |
469 |
81 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
341 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
431 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
287 |
266 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
131 |
90 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
85 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$213.68 |