| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
257 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
275 |
$58K |
| D1206 |
Topical application of fluoride varnish |
644 |
634 |
$25K |
| D0330 |
Panoramic radiographic image |
254 |
250 |
$24K |
| D0274 |
Bitewings - four radiographic images |
447 |
435 |
$22K |
| D1120 |
Prophylaxis - child |
436 |
428 |
$22K |
| D1110 |
Prophylaxis - adult |
267 |
257 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
454 |
435 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
240 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
353 |
338 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
71 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
108 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
71 |
66 |
$4K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$4K |
| D7111 |
|
23 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
12 |
$615.00 |