| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
517 |
250 |
$72K |
| D1120 |
Prophylaxis - child |
1,025 |
1,025 |
$30K |
| D1110 |
Prophylaxis - adult |
558 |
558 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,157 |
1,157 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,575 |
1,575 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
675 |
637 |
$17K |
| D0330 |
Panoramic radiographic image |
346 |
346 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
423 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
54 |
$8K |
| D0274 |
Bitewings - four radiographic images |
294 |
294 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
265 |
264 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
529 |
$8K |
| D0272 |
Bitewings - two radiographic images |
319 |
319 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
26 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
175 |
$2K |