| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
652 |
386 |
$48K |
| D1110 |
Prophylaxis - adult |
858 |
845 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,383 |
1,360 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
635 |
$21K |
| D0274 |
Bitewings - four radiographic images |
721 |
711 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
93 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
501 |
462 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
879 |
410 |
$11K |
| D1351 |
Sealant - per tooth |
301 |
96 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
600 |
595 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
814 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
689 |
618 |
$6K |
| D9630 |
|
264 |
263 |
$5K |
| D1120 |
Prophylaxis - child |
147 |
145 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$647.88 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$273.13 |