| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
162 |
$12K |
| D1120 |
Prophylaxis - child |
539 |
537 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
251 |
161 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
610 |
$9K |
| D1110 |
Prophylaxis - adult |
286 |
285 |
$8K |
| D1351 |
Sealant - per tooth |
558 |
115 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
101 |
99 |
$7K |
| D0274 |
Bitewings - four radiographic images |
329 |
328 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
760 |
757 |
$6K |
| D0272 |
Bitewings - two radiographic images |
408 |
407 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
631 |
629 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
599 |
595 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
201 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
215 |
204 |
$3K |
| D0330 |
Panoramic radiographic image |
141 |
140 |
$2K |
| D0603 |
|
768 |
767 |
$0.00 |
| D0601 |
|
27 |
27 |
$0.00 |
| D0602 |
|
69 |
69 |
$0.00 |