| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
181 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
443 |
235 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
848 |
790 |
$14K |
| D0272 |
Bitewings - two radiographic images |
790 |
735 |
$13K |
| D1110 |
Prophylaxis - adult |
390 |
359 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
835 |
776 |
$12K |
| D1120 |
Prophylaxis - child |
443 |
416 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
518 |
425 |
$10K |
| D0330 |
Panoramic radiographic image |
212 |
192 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
72 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
113 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$936.00 |
| D0240 |
|
30 |
15 |
$540.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
12 |
$290.00 |