| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
70 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
409 |
$12K |
| D1120 |
Prophylaxis - child |
274 |
272 |
$10K |
| D1110 |
Prophylaxis - adult |
123 |
122 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
420 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
187 |
$6K |
| D0274 |
Bitewings - four radiographic images |
147 |
145 |
$5K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$5K |
| D1351 |
Sealant - per tooth |
119 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
83 |
$865.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
15 |
$460.40 |
| D0603 |
|
478 |
477 |
$0.00 |