| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
237 |
$54K |
| D1351 |
Sealant - per tooth |
1,350 |
241 |
$45K |
| D1120 |
Prophylaxis - child |
1,059 |
1,028 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
1,097 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,279 |
1,244 |
$32K |
| D1110 |
Prophylaxis - adult |
314 |
307 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
291 |
$15K |
| D0330 |
Panoramic radiographic image |
272 |
264 |
$11K |
| D0272 |
Bitewings - two radiographic images |
723 |
701 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
219 |
201 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
51 |
$9K |
| D0274 |
Bitewings - four radiographic images |
347 |
339 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
231 |
223 |
$5K |
| D1330 |
|
894 |
865 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
52 |
$1K |
| D3120 |
|
18 |
14 |
$630.00 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
62 |
$603.00 |