| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
486 |
$76K |
| D1110 |
Prophylaxis - adult |
1,069 |
996 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,234 |
1,164 |
$31K |
| D1120 |
Prophylaxis - child |
705 |
676 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
715 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,212 |
1,138 |
$23K |
| D0274 |
Bitewings - four radiographic images |
603 |
571 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
179 |
122 |
$16K |
| D0330 |
Panoramic radiographic image |
234 |
207 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
803 |
734 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
97 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
70 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
56 |
$5K |
| D1351 |
Sealant - per tooth |
178 |
38 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
123 |
$4K |
| D0272 |
Bitewings - two radiographic images |
146 |
131 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
36 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
48 |
$799.58 |