| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,233 |
627 |
$119K |
| D0210 |
Intraoral - complete series of radiographic images |
1,438 |
1,415 |
$98K |
| D1351 |
Sealant - per tooth |
2,034 |
640 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,458 |
1,431 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
618 |
348 |
$44K |
| D1120 |
Prophylaxis - child |
1,166 |
1,151 |
$41K |
| D1110 |
Prophylaxis - adult |
586 |
574 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,880 |
1,852 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
584 |
573 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
92 |
92 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
347 |
344 |
$10K |
| D0274 |
Bitewings - four radiographic images |
174 |
171 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
358 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
339 |
334 |
$4K |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$2K |
| D0603 |
|
2,221 |
2,185 |
$0.00 |