| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,732 |
1,228 |
$598K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
604 |
310 |
$83K |
| D1110 |
Prophylaxis - adult |
1,020 |
1,016 |
$42K |
| D1120 |
Prophylaxis - child |
1,307 |
1,304 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,780 |
1,774 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,084 |
2,074 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,028 |
1,000 |
$32K |
| D2330 |
|
219 |
95 |
$21K |
| D0330 |
Panoramic radiographic image |
290 |
289 |
$15K |
| D0274 |
Bitewings - four radiographic images |
412 |
412 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
240 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
24 |
$6K |
| D0272 |
Bitewings - two radiographic images |
266 |
265 |
$5K |
| D3120 |
|
119 |
53 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
192 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
111 |
$1K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$599.62 |