| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
83 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,124 |
$32K |
| D1120 |
Prophylaxis - child |
672 |
664 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,268 |
1,248 |
$18K |
| D1110 |
Prophylaxis - adult |
265 |
259 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
28 |
$12K |
| D1351 |
Sealant - per tooth |
466 |
69 |
$11K |
| D0274 |
Bitewings - four radiographic images |
304 |
295 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
102 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
40 |
$6K |
| D0272 |
Bitewings - two radiographic images |
123 |
119 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$325.32 |
| D0602 |
|
1,062 |
1,047 |
$0.00 |
| D0601 |
|
105 |
102 |
$0.00 |
| D0603 |
|
27 |
27 |
$0.00 |