| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
276 |
$67K |
| D1206 |
Topical application of fluoride varnish |
971 |
931 |
$36K |
| D1120 |
Prophylaxis - child |
590 |
565 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
668 |
$24K |
| D1110 |
Prophylaxis - adult |
290 |
276 |
$21K |
| D0274 |
Bitewings - four radiographic images |
420 |
407 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
199 |
$16K |
| D0330 |
Panoramic radiographic image |
140 |
134 |
$14K |
| D0272 |
Bitewings - two radiographic images |
372 |
351 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
37 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
79 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
256 |
$6K |
| D1351 |
Sealant - per tooth |
128 |
40 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
71 |
37 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
53 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
26 |
$1K |