| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
174 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
835 |
815 |
$20K |
| D1206 |
Topical application of fluoride varnish |
861 |
837 |
$18K |
| D1120 |
Prophylaxis - child |
534 |
516 |
$18K |
| D1110 |
Prophylaxis - adult |
403 |
395 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
400 |
360 |
$12K |
| D0274 |
Bitewings - four radiographic images |
360 |
349 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
658 |
631 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
62 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
551 |
$4K |
| D0330 |
Panoramic radiographic image |
114 |
107 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
102 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
30 |
$3K |
| D0272 |
Bitewings - two radiographic images |
163 |
155 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$317.69 |
| D0191 |
|
51 |
51 |
$0.00 |
| D9995 |
|
51 |
51 |
$0.00 |