| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,274 |
506 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,615 |
2,590 |
$71K |
| D1110 |
Prophylaxis - adult |
1,377 |
1,356 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,154 |
462 |
$62K |
| D1120 |
Prophylaxis - child |
1,584 |
1,579 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,351 |
2,330 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,586 |
1,559 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,058 |
1,016 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
769 |
703 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
226 |
$9K |
| D0999 |
Unspecified diagnostic procedure, by report |
172 |
101 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
96 |
$3K |
| D0330 |
Panoramic radiographic image |
89 |
56 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.42 |