| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,019 |
468 |
$101K |
| D1351 |
Sealant - per tooth |
1,208 |
355 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,102 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,627 |
1,018 |
$29K |
| D1120 |
Prophylaxis - child |
787 |
782 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
183 |
183 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
647 |
607 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,135 |
1,129 |
$16K |
| D1110 |
Prophylaxis - adult |
309 |
305 |
$16K |
| D0274 |
Bitewings - four radiographic images |
439 |
435 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,089 |
1,066 |
$13K |
| D0272 |
Bitewings - two radiographic images |
246 |
243 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D1330 |
|
20 |
18 |
$196.00 |
| D0603 |
|
1,159 |
1,152 |
$0.00 |
| D0601 |
|
183 |
183 |
$0.00 |