| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,637 |
1,527 |
$457K |
| D1110 |
Prophylaxis - adult |
3,441 |
3,441 |
$173K |
| D0120 |
Periodic oral evaluation - established patient |
5,995 |
5,995 |
$138K |
| D1120 |
Prophylaxis - child |
3,330 |
3,330 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,626 |
6,626 |
$108K |
| D0272 |
Bitewings - two radiographic images |
4,455 |
4,455 |
$84K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,382 |
2,341 |
$77K |
| D0330 |
Panoramic radiographic image |
1,142 |
1,142 |
$57K |
| D0274 |
Bitewings - four radiographic images |
957 |
957 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
130 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
373 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
245 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
51 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
268 |
$3K |
| D2332 |
|
13 |
12 |
$1K |
| D2140 |
|
15 |
14 |
$916.35 |