| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,682 |
742 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
5,059 |
4,998 |
$149K |
| D1110 |
Prophylaxis - adult |
2,468 |
2,433 |
$129K |
| D1206 |
Topical application of fluoride varnish |
4,353 |
4,304 |
$102K |
| D0274 |
Bitewings - four radiographic images |
2,315 |
2,299 |
$82K |
| D1120 |
Prophylaxis - child |
2,056 |
2,030 |
$79K |
| D9920 |
|
519 |
519 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
112 |
$14K |
| D0272 |
Bitewings - two radiographic images |
226 |
216 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
24 |
$5K |
| D1351 |
Sealant - per tooth |
197 |
55 |
$4K |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
172 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$529.92 |