| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
972 |
439 |
$64K |
| D1110 |
Prophylaxis - adult |
992 |
950 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
256 |
$39K |
| D9630 |
|
2,054 |
1,986 |
$36K |
| D1120 |
Prophylaxis - child |
1,116 |
1,111 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,627 |
1,607 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,300 |
$27K |
| D0274 |
Bitewings - four radiographic images |
811 |
797 |
$20K |
| D1351 |
Sealant - per tooth |
478 |
178 |
$16K |
| D1206 |
Topical application of fluoride varnish |
706 |
706 |
$12K |
| D0330 |
Panoramic radiographic image |
266 |
229 |
$12K |
| D9920 |
|
148 |
139 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
255 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
609 |
527 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
150 |
134 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
95 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
25 |
$447.20 |
| D3120 |
|
37 |
12 |
$405.02 |