| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
210 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
157 |
$37K |
| D0330 |
Panoramic radiographic image |
320 |
314 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
341 |
$25K |
| D1120 |
Prophylaxis - child |
366 |
357 |
$17K |
| D1206 |
Topical application of fluoride varnish |
423 |
414 |
$16K |
| D0274 |
Bitewings - four radiographic images |
196 |
189 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
112 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
187 |
$8K |
| D1110 |
Prophylaxis - adult |
90 |
89 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
104 |
85 |
$7K |
| D0272 |
Bitewings - two radiographic images |
172 |
168 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
234 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
55 |
$3K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$2K |