| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
106 |
$23K |
| D1110 |
Prophylaxis - adult |
398 |
398 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
434 |
434 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
59 |
$15K |
| D1206 |
Topical application of fluoride varnish |
798 |
798 |
$15K |
| D1120 |
Prophylaxis - child |
374 |
374 |
$12K |
| D1351 |
Sealant - per tooth |
225 |
71 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
319 |
319 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
292 |
$7K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
340 |
$4K |
| D0272 |
Bitewings - two radiographic images |
198 |
198 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
101 |
$4K |
| D0240 |
|
75 |
75 |
$3K |