| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
628 |
342 |
$55K |
| D1120 |
Prophylaxis - child |
1,818 |
1,818 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,263 |
2,263 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,464 |
2,464 |
$36K |
| D1110 |
Prophylaxis - adult |
684 |
684 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
729 |
685 |
$19K |
| D0330 |
Panoramic radiographic image |
411 |
411 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,233 |
1,227 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,286 |
1,042 |
$16K |
| D0274 |
Bitewings - four radiographic images |
472 |
472 |
$13K |
| D0272 |
Bitewings - two radiographic images |
480 |
480 |
$8K |
| D1351 |
Sealant - per tooth |
256 |
82 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
166 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
51 |
$4K |