| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
411 |
80 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
740 |
714 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,711 |
985 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
105 |
102 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,051 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
904 |
872 |
$12K |
| D0274 |
Bitewings - four radiographic images |
375 |
362 |
$12K |
| D1110 |
Prophylaxis - adult |
231 |
218 |
$10K |
| D1120 |
Prophylaxis - child |
301 |
287 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
32 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
21 |
$8K |
| D1351 |
Sealant - per tooth |
122 |
26 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
72 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$264.60 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$257.18 |
| D0603 |
|
1,713 |
1,655 |
$0.00 |