| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,969 |
1,194 |
$620K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
673 |
327 |
$91K |
| D1110 |
Prophylaxis - adult |
1,315 |
1,301 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,900 |
1,882 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,000 |
1,984 |
$34K |
| D1120 |
Prophylaxis - child |
1,093 |
1,093 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
872 |
850 |
$27K |
| D0274 |
Bitewings - four radiographic images |
626 |
617 |
$18K |
| D0330 |
Panoramic radiographic image |
273 |
273 |
$14K |
| D2330 |
|
90 |
38 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
182 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$4K |
| D3120 |
|
115 |
55 |
$4K |
| D0272 |
Bitewings - two radiographic images |
194 |
194 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
139 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
51 |
$658.88 |