| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,155 |
734 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
584 |
395 |
$53K |
| D1351 |
Sealant - per tooth |
1,610 |
489 |
$50K |
| D1120 |
Prophylaxis - child |
1,189 |
1,165 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,803 |
1,764 |
$46K |
| D1110 |
Prophylaxis - adult |
778 |
765 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,854 |
1,817 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
505 |
476 |
$22K |
| D0330 |
Panoramic radiographic image |
289 |
280 |
$19K |
| D0274 |
Bitewings - four radiographic images |
271 |
270 |
$10K |
| D0272 |
Bitewings - two radiographic images |
374 |
367 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
63 |
$945.78 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$462.00 |
| D9986 |
|
39 |
39 |
$0.00 |
| D9987 |
|
129 |
127 |
$0.00 |