| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
307 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
438 |
284 |
$68K |
| D1120 |
Prophylaxis - child |
1,201 |
1,179 |
$65K |
| D0330 |
Panoramic radiographic image |
567 |
555 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,359 |
1,338 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,253 |
1,227 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
587 |
$45K |
| D1110 |
Prophylaxis - adult |
537 |
524 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,011 |
985 |
$40K |
| D0274 |
Bitewings - four radiographic images |
537 |
530 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
275 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
713 |
692 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
59 |
$13K |
| D1351 |
Sealant - per tooth |
227 |
64 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
162 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
83 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
170 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$876.00 |