| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,924 |
970 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,903 |
803 |
$186K |
| D1351 |
Sealant - per tooth |
5,343 |
1,272 |
$175K |
| D1120 |
Prophylaxis - child |
2,309 |
2,309 |
$90K |
| D1206 |
Topical application of fluoride varnish |
3,564 |
3,542 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,626 |
1,616 |
$75K |
| D0272 |
Bitewings - two radiographic images |
1,348 |
1,336 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,096 |
1,095 |
$33K |
| D0274 |
Bitewings - four radiographic images |
609 |
608 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
454 |
356 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
714 |
$13K |
| D1110 |
Prophylaxis - adult |
230 |
228 |
$12K |
| D7111 |
|
129 |
74 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
195 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
27 |
$5K |
| D1354 |
|
118 |
44 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
47 |
47 |
$1K |
| D1353 |
|
38 |
21 |
$1K |
| D1330 |
|
49 |
49 |
$1K |