| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
252 |
$56K |
| D1206 |
Topical application of fluoride varnish |
868 |
838 |
$33K |
| D1120 |
Prophylaxis - child |
591 |
568 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
723 |
697 |
$26K |
| D0274 |
Bitewings - four radiographic images |
404 |
399 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
79 |
$14K |
| D0330 |
Panoramic radiographic image |
187 |
182 |
$14K |
| D1110 |
Prophylaxis - adult |
216 |
211 |
$12K |
| D0272 |
Bitewings - two radiographic images |
227 |
215 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$6K |
| D1351 |
Sealant - per tooth |
64 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
117 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
40 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$1K |