| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
107 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
211 |
80 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
167 |
$3K |
| D1120 |
Prophylaxis - child |
124 |
116 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
81 |
$2K |
| D1351 |
Sealant - per tooth |
105 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
174 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
89 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
90 |
$376.80 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$375.05 |
| D0603 |
|
211 |
198 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$0.00 |