| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,635 |
866 |
$152K |
| D1110 |
Prophylaxis - adult |
2,179 |
2,179 |
$109K |
| D0274 |
Bitewings - four radiographic images |
2,253 |
2,253 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,393 |
1,393 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,118 |
2,118 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,920 |
2,920 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
603 |
378 |
$43K |
| D1120 |
Prophylaxis - child |
1,177 |
1,177 |
$41K |
| D0330 |
Panoramic radiographic image |
619 |
619 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
486 |
483 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,172 |
1,163 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
68 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
272 |
272 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
921 |
655 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
57 |
$2K |
| D1351 |
Sealant - per tooth |
60 |
16 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
15 |
$2K |