| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,862 |
687 |
$190K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,073 |
508 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
601 |
598 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
200 |
200 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
743 |
736 |
$26K |
| D1120 |
Prophylaxis - child |
626 |
619 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
805 |
797 |
$21K |
| D1110 |
Prophylaxis - adult |
291 |
290 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
914 |
905 |
$13K |
| D1351 |
Sealant - per tooth |
463 |
128 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,109 |
327 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
188 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
337 |
$4K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D0603 |
|
1,161 |
1,149 |
$0.00 |