| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
569 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
3,231 |
3,179 |
$146K |
| D1120 |
Prophylaxis - child |
2,392 |
2,352 |
$146K |
| D1206 |
Topical application of fluoride varnish |
3,140 |
3,085 |
$119K |
| D0274 |
Bitewings - four radiographic images |
1,904 |
1,867 |
$107K |
| D1110 |
Prophylaxis - adult |
760 |
743 |
$60K |
| D0272 |
Bitewings - two radiographic images |
1,210 |
1,200 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
590 |
523 |
$38K |
| D1351 |
Sealant - per tooth |
672 |
181 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
106 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
447 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
128 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
147 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
51 |
$3K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
29 |
$1K |