| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,258 |
245 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
535 |
165 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
357 |
357 |
$50K |
| D1120 |
Prophylaxis - child |
314 |
306 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
229 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
562 |
536 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
271 |
$8K |
| D1110 |
Prophylaxis - adult |
128 |
121 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
79 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
393 |
258 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
321 |
$4K |
| D1351 |
Sealant - per tooth |
152 |
53 |
$4K |
| D0274 |
Bitewings - four radiographic images |
76 |
72 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
20 |
$569.31 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$561.12 |
| D0603 |
|
1,081 |
1,062 |
$0.00 |