| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,023 |
320 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,399 |
696 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
360 |
108 |
$26K |
| D1351 |
Sealant - per tooth |
595 |
125 |
$16K |
| D1120 |
Prophylaxis - child |
415 |
401 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
360 |
$12K |
| D0272 |
Bitewings - two radiographic images |
509 |
500 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
404 |
389 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
75 |
71 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
812 |
789 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
610 |
594 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
231 |
$7K |
| D0240 |
|
32 |
16 |
$313.60 |
| D0603 |
|
1,086 |
1,052 |
$0.00 |