| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
84 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
574 |
114 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
133 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
123 |
$2K |
| D2330 |
|
27 |
14 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$994.49 |
| D1120 |
Prophylaxis - child |
65 |
65 |
$768.05 |
| D1351 |
Sealant - per tooth |
70 |
15 |
$614.56 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$382.20 |
| D1330 |
|
58 |
58 |
$343.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$218.42 |
| D0603 |
|
190 |
190 |
$0.00 |