| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
126 |
$22K |
| D1120 |
Prophylaxis - child |
412 |
412 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
60 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
166 |
147 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
226 |
$5K |
| D1351 |
Sealant - per tooth |
156 |
54 |
$4K |
| D1206 |
Topical application of fluoride varnish |
228 |
228 |
$4K |
| D0272 |
Bitewings - two radiographic images |
137 |
137 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
147 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$396.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
27 |
$390.44 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$330.12 |