| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
186 |
$30K |
| D1351 |
Sealant - per tooth |
344 |
122 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
107 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
62 |
$12K |
| D1120 |
Prophylaxis - child |
257 |
251 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
266 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
228 |
$7K |
| D1354 |
|
177 |
94 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
94 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$4K |
| D0272 |
Bitewings - two radiographic images |
139 |
136 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
98 |
$973.17 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$390.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$255.58 |