| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
713 |
348 |
$77K |
| D1120 |
Prophylaxis - child |
1,514 |
1,403 |
$75K |
| D1206 |
Topical application of fluoride varnish |
1,809 |
1,684 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
671 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,095 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
408 |
200 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
721 |
500 |
$15K |
| D1110 |
Prophylaxis - adult |
209 |
197 |
$14K |
| D0272 |
Bitewings - two radiographic images |
351 |
273 |
$9K |
| D0274 |
Bitewings - four radiographic images |
105 |
87 |
$4K |
| D1351 |
Sealant - per tooth |
73 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
24 |
$564.00 |