| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
272 |
$50K |
| D1120 |
Prophylaxis - child |
1,766 |
1,523 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
859 |
688 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
598 |
$23K |
| D1206 |
Topical application of fluoride varnish |
951 |
833 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
757 |
$20K |
| D0330 |
Panoramic radiographic image |
412 |
350 |
$15K |
| D0272 |
Bitewings - two radiographic images |
604 |
514 |
$8K |
| D1351 |
Sealant - per tooth |
176 |
32 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
42 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
508 |
404 |
$5K |
| D0274 |
Bitewings - four radiographic images |
200 |
180 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
256 |
195 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
75 |
48 |
$1K |