| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
680 |
456 |
$52K |
| D1120 |
Prophylaxis - child |
936 |
936 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
663 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
590 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
242 |
199 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
733 |
733 |
$10K |
| D1206 |
Topical application of fluoride varnish |
329 |
329 |
$9K |
| D0272 |
Bitewings - two radiographic images |
419 |
419 |
$7K |
| D1351 |
Sealant - per tooth |
188 |
55 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
63 |
$6K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
40 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
290 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$2K |