| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
230 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
198 |
$28K |
| D1120 |
Prophylaxis - child |
676 |
674 |
$28K |
| D9920 |
|
294 |
287 |
$25K |
| D1206 |
Topical application of fluoride varnish |
878 |
876 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
406 |
402 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
670 |
669 |
$17K |
| D1110 |
Prophylaxis - adult |
225 |
225 |
$13K |
| D1351 |
Sealant - per tooth |
325 |
114 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
198 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
112 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
441 |
163 |
$6K |
| D0272 |
Bitewings - two radiographic images |
165 |
164 |
$4K |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
229 |
$3K |
| D0240 |
|
193 |
111 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$1K |