| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
790 |
432 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,240 |
1,219 |
$34K |
| D1351 |
Sealant - per tooth |
1,205 |
320 |
$31K |
| D1120 |
Prophylaxis - child |
830 |
813 |
$28K |
| D1110 |
Prophylaxis - adult |
522 |
519 |
$27K |
| D0274 |
Bitewings - four radiographic images |
636 |
627 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
193 |
127 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
227 |
133 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,177 |
1,155 |
$16K |
| D0272 |
Bitewings - two radiographic images |
623 |
609 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
75 |
75 |
$10K |
| D0330 |
Panoramic radiographic image |
197 |
195 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
153 |
133 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
221 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
177 |
$2K |
| D1206 |
Topical application of fluoride varnish |
117 |
117 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$953.64 |
| D0603 |
|
1,478 |
1,460 |
$0.00 |