| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
258 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,530 |
1,410 |
$50K |
| D1120 |
Prophylaxis - child |
1,384 |
1,272 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,688 |
1,544 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
671 |
574 |
$28K |
| D1110 |
Prophylaxis - adult |
331 |
311 |
$19K |
| D0272 |
Bitewings - two radiographic images |
541 |
502 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
43 |
$6K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$4K |
| D1351 |
Sealant - per tooth |
97 |
28 |
$3K |
| D1354 |
|
86 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
67 |
$977.50 |
| D0240 |
|
55 |
29 |
$870.26 |
| D3120 |
|
18 |
15 |
$453.24 |
| D1330 |
|
19 |
16 |
$0.00 |
| D0603 |
|
14 |
13 |
$0.00 |