| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
554 |
329 |
$48K |
| D1110 |
Prophylaxis - adult |
630 |
603 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
854 |
$21K |
| D1120 |
Prophylaxis - child |
623 |
580 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
330 |
309 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
745 |
698 |
$11K |
| D0274 |
Bitewings - four radiographic images |
370 |
352 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
265 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
53 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
49 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
128 |
111 |
$5K |
| D1351 |
Sealant - per tooth |
165 |
56 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
297 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
29 |
$4K |
| D1206 |
Topical application of fluoride varnish |
191 |
187 |
$3K |
| D0272 |
Bitewings - two radiographic images |
204 |
189 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
35 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
54 |
$898.83 |