| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
267 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
277 |
129 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
882 |
761 |
$31K |
| D1351 |
Sealant - per tooth |
1,012 |
181 |
$24K |
| D1120 |
Prophylaxis - child |
979 |
815 |
$23K |
| D1206 |
Topical application of fluoride varnish |
834 |
735 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
394 |
324 |
$14K |
| D0330 |
Panoramic radiographic image |
328 |
299 |
$12K |
| D0274 |
Bitewings - four radiographic images |
340 |
295 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
258 |
215 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
100 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
42 |
$6K |
| D0272 |
Bitewings - two radiographic images |
317 |
286 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
275 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
53 |
$620.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$233.40 |