| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
281 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
301 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
821 |
757 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
579 |
$14K |
| D1120 |
Prophylaxis - child |
513 |
513 |
$11K |
| D1206 |
Topical application of fluoride varnish |
744 |
744 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
839 |
836 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
298 |
281 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$6K |
| D0330 |
Panoramic radiographic image |
170 |
170 |
$6K |
| D1110 |
Prophylaxis - adult |
191 |
191 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
66 |
$5K |
| D0350 |
|
86 |
80 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$1K |
| D1351 |
Sealant - per tooth |
67 |
32 |
$1K |
| D3120 |
|
33 |
24 |
$888.00 |