| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,762 |
399 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
176 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
634 |
624 |
$16K |
| D1120 |
Prophylaxis - child |
372 |
367 |
$13K |
| D1110 |
Prophylaxis - adult |
302 |
290 |
$13K |
| D1206 |
Topical application of fluoride varnish |
584 |
570 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
26 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
210 |
$7K |
| D0274 |
Bitewings - four radiographic images |
188 |
184 |
$6K |
| D2330 |
|
49 |
25 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D3120 |
|
51 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$1K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
79 |
$935.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$443.18 |