| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
622 |
261 |
$60K |
| D1351 |
Sealant - per tooth |
1,114 |
183 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
775 |
$22K |
| D1120 |
Prophylaxis - child |
567 |
536 |
$19K |
| D1110 |
Prophylaxis - adult |
346 |
335 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
821 |
783 |
$11K |
| D0272 |
Bitewings - two radiographic images |
514 |
491 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
67 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
800 |
761 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
761 |
720 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
318 |
296 |
$8K |
| D0274 |
Bitewings - four radiographic images |
184 |
180 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
46 |
43 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
56 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$988.96 |
| D0603 |
|
1,119 |
1,076 |
$0.00 |