| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
829 |
326 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
456 |
248 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
330 |
179 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
621 |
621 |
$27K |
| D1110 |
Prophylaxis - adult |
495 |
495 |
$26K |
| D0274 |
Bitewings - four radiographic images |
488 |
488 |
$14K |
| D1206 |
Topical application of fluoride varnish |
801 |
801 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
360 |
$9K |
| D1120 |
Prophylaxis - child |
249 |
249 |
$9K |
| D0330 |
Panoramic radiographic image |
158 |
158 |
$7K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$3K |
| D1351 |
Sealant - per tooth |
54 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
67 |
$920.60 |