| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,382 |
715 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,510 |
669 |
$102K |
| D1120 |
Prophylaxis - child |
2,866 |
2,851 |
$85K |
| D1206 |
Topical application of fluoride varnish |
4,589 |
4,563 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
4,274 |
4,250 |
$73K |
| D1110 |
Prophylaxis - adult |
1,451 |
1,442 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,020 |
975 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,303 |
2,286 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,155 |
2,087 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,032 |
1,029 |
$19K |
| D0274 |
Bitewings - four radiographic images |
315 |
315 |
$8K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |