| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,575 |
765 |
$138K |
| D1120 |
Prophylaxis - child |
2,868 |
2,868 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,750 |
3,750 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,278 |
4,278 |
$62K |
| D1110 |
Prophylaxis - adult |
1,429 |
1,429 |
$62K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,804 |
1,668 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,756 |
2,710 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,336 |
1,336 |
$23K |
| D0240 |
|
1,233 |
1,233 |
$22K |
| D0274 |
Bitewings - four radiographic images |
710 |
710 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
365 |
203 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,506 |
1,206 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
226 |
$7K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$4K |
| D1351 |
Sealant - per tooth |
94 |
31 |
$2K |
| D3120 |
|
38 |
30 |
$1K |
| D1206 |
Topical application of fluoride varnish |
20 |
20 |
$365.80 |