| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
296 |
175 |
$37K |
| D1120 |
Prophylaxis - child |
425 |
423 |
$20K |
| D9420 |
|
35 |
35 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
493 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
90 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
186 |
175 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
581 |
577 |
$12K |
| D1110 |
Prophylaxis - adult |
159 |
159 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,402 |
541 |
$10K |
| D0272 |
Bitewings - two radiographic images |
326 |
325 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
35 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
592 |
581 |
$7K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
90 |
$4K |
| D1351 |
Sealant - per tooth |
112 |
49 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$3K |
| D1330 |
|
534 |
532 |
$3K |
| D9920 |
|
52 |
50 |
$3K |
| D3120 |
|
36 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$478.10 |
| D0602 |
|
28 |
28 |
$125.50 |