| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
382 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
297 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,001 |
964 |
$38K |
| D0274 |
Bitewings - four radiographic images |
666 |
647 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
798 |
764 |
$31K |
| D1120 |
Prophylaxis - child |
626 |
604 |
$31K |
| D1110 |
Prophylaxis - adult |
347 |
334 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
164 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
168 |
117 |
$9K |
| D0330 |
Panoramic radiographic image |
102 |
100 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
347 |
339 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
164 |
$7K |
| D1351 |
Sealant - per tooth |
191 |
45 |
$6K |
| D0272 |
Bitewings - two radiographic images |
148 |
140 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$3K |