| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,322 |
502 |
$180K |
| D1110 |
Prophylaxis - adult |
1,238 |
1,238 |
$62K |
| D9248 |
|
784 |
750 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,840 |
1,840 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
315 |
115 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,976 |
1,976 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,819 |
1,819 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
854 |
822 |
$28K |
| D1120 |
Prophylaxis - child |
597 |
597 |
$21K |
| D9920 |
|
161 |
161 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
43 |
$7K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
14 |
$930.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$458.60 |