| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,155 |
628 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
740 |
437 |
$41K |
| D1110 |
Prophylaxis - adult |
856 |
856 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,154 |
1,154 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,421 |
1,421 |
$36K |
| D1120 |
Prophylaxis - child |
746 |
746 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
238 |
178 |
$20K |
| D1351 |
Sealant - per tooth |
987 |
213 |
$20K |
| D0274 |
Bitewings - four radiographic images |
912 |
912 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,376 |
1,373 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
148 |
148 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,232 |
1,230 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$6K |
| D0603 |
|
557 |
557 |
$6K |
| D0272 |
Bitewings - two radiographic images |
273 |
273 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$2K |
| D1353 |
|
191 |
38 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$625.00 |
| D0601 |
|
34 |
34 |
$340.00 |