| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
836 |
243 |
$82K |
| D1120 |
Prophylaxis - child |
1,206 |
1,204 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,457 |
1,454 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
248 |
248 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
317 |
125 |
$25K |
| D1110 |
Prophylaxis - adult |
485 |
483 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,746 |
1,742 |
$25K |
| D0274 |
Bitewings - four radiographic images |
825 |
819 |
$23K |
| D0272 |
Bitewings - two radiographic images |
862 |
859 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,803 |
1,789 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,737 |
1,724 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
165 |
$6K |
| D0330 |
Panoramic radiographic image |
200 |
198 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D1351 |
Sealant - per tooth |
77 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
59 |
$2K |
| D0603 |
|
2,122 |
2,116 |
$0.00 |