| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
987 |
630 |
$109K |
| D1120 |
Prophylaxis - child |
2,487 |
2,485 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,125 |
3,122 |
$74K |
| D1110 |
Prophylaxis - adult |
942 |
941 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,421 |
1,421 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
254 |
$26K |
| D0272 |
Bitewings - two radiographic images |
798 |
798 |
$16K |
| D0274 |
Bitewings - four radiographic images |
450 |
450 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
174 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
180 |
$7K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$936.12 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$458.03 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$352.11 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
43 |
$0.00 |