| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,188 |
354 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
767 |
251 |
$60K |
| D0145 |
Oral evaluation for a patient under three years of age |
155 |
154 |
$21K |
| D1120 |
Prophylaxis - child |
506 |
505 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,536 |
592 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
605 |
604 |
$17K |
| D1351 |
Sealant - per tooth |
517 |
159 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
473 |
467 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
698 |
696 |
$10K |
| D1110 |
Prophylaxis - adult |
168 |
167 |
$9K |
| D0274 |
Bitewings - four radiographic images |
248 |
246 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
119 |
119 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
617 |
614 |
$8K |
| D0272 |
Bitewings - two radiographic images |
194 |
194 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
127 |
$4K |
| D1330 |
|
27 |
27 |
$306.25 |
| D0603 |
|
936 |
930 |
$0.00 |