| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
103 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
237 |
$16K |
| D1351 |
Sealant - per tooth |
681 |
159 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
67 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
247 |
$9K |
| D1120 |
Prophylaxis - child |
225 |
214 |
$8K |
| D0350 |
|
330 |
316 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
193 |
184 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
328 |
313 |
$5K |
| D1110 |
Prophylaxis - adult |
86 |
82 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$346.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
13 |
$310.77 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$288.88 |
| D0603 |
|
404 |
390 |
$0.00 |