| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
202 |
$64K |
| D1110 |
Prophylaxis - adult |
921 |
908 |
$59K |
| D1120 |
Prophylaxis - child |
1,252 |
1,244 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,815 |
1,799 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,110 |
2,086 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
783 |
772 |
$43K |
| D2750 |
|
72 |
44 |
$33K |
| D0330 |
Panoramic radiographic image |
634 |
626 |
$29K |
| D0274 |
Bitewings - four radiographic images |
550 |
542 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
198 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
13 |
$6K |
| D4355 |
|
55 |
54 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
233 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
131 |
$3K |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$2K |