| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
240 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
362 |
233 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
611 |
601 |
$15K |
| D1120 |
Prophylaxis - child |
559 |
547 |
$12K |
| D1206 |
Topical application of fluoride varnish |
733 |
719 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
691 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
741 |
727 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
163 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
54 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
128 |
87 |
$6K |
| D1110 |
Prophylaxis - adult |
184 |
182 |
$5K |
| D0272 |
Bitewings - two radiographic images |
248 |
244 |
$3K |
| D0330 |
Panoramic radiographic image |
105 |
100 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
128 |
$3K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
153 |
$3K |
| D1351 |
Sealant - per tooth |
98 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
21 |
21 |
$496.00 |