| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
7,161 |
1,316 |
$738K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
245 |
$65K |
| D1110 |
Prophylaxis - adult |
1,443 |
1,432 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,505 |
1,499 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,859 |
1,854 |
$34K |
| D0330 |
Panoramic radiographic image |
588 |
585 |
$30K |
| D1120 |
Prophylaxis - child |
901 |
900 |
$29K |
| D0274 |
Bitewings - four radiographic images |
796 |
792 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
592 |
589 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
738 |
725 |
$23K |
| D2330 |
|
89 |
40 |
$9K |
| D0272 |
Bitewings - two radiographic images |
198 |
198 |
$4K |
| D1351 |
Sealant - per tooth |
78 |
24 |
$3K |
| D3120 |
|
67 |
28 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
72 |
$861.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
41 |
$491.14 |