| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,156 |
584 |
$97K |
| D1110 |
Prophylaxis - adult |
2,536 |
2,517 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,370 |
3,191 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,646 |
1,635 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,699 |
1,688 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,008 |
1,003 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
856 |
751 |
$24K |
| D0330 |
Panoramic radiographic image |
412 |
407 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,495 |
2,435 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
124 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,985 |
1,953 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
78 |
$11K |
| D1999 |
|
910 |
837 |
$9K |
| D4341 |
|
29 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
125 |
$3K |
| D1120 |
Prophylaxis - child |
80 |
79 |
$2K |