| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,282 |
273 |
$129K |
| D1351 |
Sealant - per tooth |
1,478 |
251 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
252 |
250 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
514 |
507 |
$35K |
| D1120 |
Prophylaxis - child |
878 |
867 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,294 |
1,281 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
552 |
544 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
619 |
$18K |
| D1110 |
Prophylaxis - adult |
236 |
235 |
$13K |
| D5986 |
|
260 |
256 |
$12K |
| D0274 |
Bitewings - four radiographic images |
350 |
348 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
330 |
264 |
$9K |
| D0272 |
Bitewings - two radiographic images |
457 |
453 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
666 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
664 |
658 |
$8K |
| D0330 |
Panoramic radiographic image |
145 |
144 |
$61.00 |
| D0603 |
|
1,551 |
1,524 |
$0.00 |
| D0601 |
|
65 |
65 |
$0.00 |