| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
302 |
$92K |
| D1120 |
Prophylaxis - child |
1,150 |
1,106 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,494 |
1,446 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,525 |
1,467 |
$49K |
| D1110 |
Prophylaxis - adult |
525 |
504 |
$36K |
| D0274 |
Bitewings - four radiographic images |
612 |
593 |
$31K |
| D0330 |
Panoramic radiographic image |
367 |
351 |
$30K |
| D0272 |
Bitewings - two radiographic images |
829 |
801 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
129 |
$28K |
| D9920 |
|
186 |
173 |
$22K |
| D1351 |
Sealant - per tooth |
239 |
67 |
$11K |
| D7111 |
|
89 |
46 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
115 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
142 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
30 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$1K |
| D0603 |
|
835 |
803 |
$0.00 |
| D0602 |
|
417 |
403 |
$0.00 |
| D0601 |
|
349 |
333 |
$0.00 |