| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,835 |
689 |
$280K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,398 |
415 |
$111K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,018 |
983 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
913 |
908 |
$30K |
| D1120 |
Prophylaxis - child |
674 |
669 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
725 |
720 |
$19K |
| D1110 |
Prophylaxis - adult |
276 |
276 |
$15K |
| D0272 |
Bitewings - two radiographic images |
639 |
637 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
993 |
988 |
$14K |
| D2330 |
|
164 |
77 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
988 |
983 |
$12K |
| D1351 |
Sealant - per tooth |
152 |
37 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$2K |
| D0603 |
|
1,074 |
1,068 |
$0.00 |