| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
161 |
$27K |
| D1120 |
Prophylaxis - child |
528 |
528 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
508 |
438 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
203 |
114 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
717 |
717 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
454 |
454 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
342 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
162 |
$5K |
| D0330 |
Panoramic radiographic image |
95 |
95 |
$4K |
| D1351 |
Sealant - per tooth |
186 |
57 |
$4K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
376 |
137 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0240 |
|
24 |
12 |
$418.32 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$395.28 |