| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
332 |
247 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
416 |
311 |
$41K |
| D1351 |
Sealant - per tooth |
984 |
335 |
$33K |
| D1110 |
Prophylaxis - adult |
408 |
408 |
$23K |
| D0274 |
Bitewings - four radiographic images |
456 |
456 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
577 |
577 |
$18K |
| D1206 |
Topical application of fluoride varnish |
734 |
734 |
$18K |
| D0330 |
Panoramic radiographic image |
215 |
215 |
$16K |
| D1120 |
Prophylaxis - child |
338 |
338 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
54 |
$9K |
| D0272 |
Bitewings - two radiographic images |
275 |
275 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
19 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
155 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
16 |
$886.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
28 |
$831.00 |