| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
284 |
144 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
622 |
$14K |
| D1110 |
Prophylaxis - adult |
419 |
381 |
$12K |
| D1351 |
Sealant - per tooth |
549 |
121 |
$11K |
| D0274 |
Bitewings - four radiographic images |
472 |
436 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
831 |
750 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
930 |
693 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
173 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
600 |
570 |
$7K |
| D1120 |
Prophylaxis - child |
329 |
310 |
$7K |
| D0330 |
Panoramic radiographic image |
194 |
184 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
79 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
148 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$337.00 |