| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
832 |
418 |
$98K |
| D1120 |
Prophylaxis - child |
1,060 |
1,052 |
$45K |
| D1351 |
Sealant - per tooth |
1,351 |
311 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,606 |
1,589 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,195 |
1,187 |
$35K |
| D1110 |
Prophylaxis - adult |
425 |
419 |
$24K |
| D0274 |
Bitewings - four radiographic images |
671 |
662 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
239 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
70 |
$10K |
| D0330 |
Panoramic radiographic image |
200 |
198 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
24 |
$6K |
| D0272 |
Bitewings - two radiographic images |
407 |
403 |
$6K |
| D1330 |
|
866 |
854 |
$5K |
| D3120 |
|
97 |
44 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
119 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$108.00 |