| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,047 |
562 |
$108K |
| D1120 |
Prophylaxis - child |
3,994 |
3,953 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
4,082 |
4,037 |
$103K |
| D1206 |
Topical application of fluoride varnish |
2,399 |
2,369 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,015 |
1,988 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
719 |
709 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,448 |
1,436 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
467 |
$20K |
| D1110 |
Prophylaxis - adult |
537 |
526 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,090 |
1,073 |
$16K |
| D0330 |
Panoramic radiographic image |
288 |
282 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
873 |
844 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
56 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
67 |
$7K |
| D0274 |
Bitewings - four radiographic images |
145 |
138 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$873.50 |