| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
237 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,009 |
1,287 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,458 |
1,389 |
$39K |
| D1120 |
Prophylaxis - child |
846 |
800 |
$28K |
| D1110 |
Prophylaxis - adult |
508 |
484 |
$26K |
| D1351 |
Sealant - per tooth |
997 |
270 |
$25K |
| D0274 |
Bitewings - four radiographic images |
749 |
707 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
165 |
160 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,534 |
1,454 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,491 |
1,396 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
74 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
53 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
44 |
$1K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$697.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
16 |
$570.80 |
| D0603 |
|
1,915 |
1,849 |
$33.00 |