| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
473 |
307 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
467 |
273 |
$18K |
| D1351 |
Sealant - per tooth |
986 |
223 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
159 |
158 |
$11K |
| D1110 |
Prophylaxis - adult |
344 |
340 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
653 |
645 |
$10K |
| D1120 |
Prophylaxis - child |
449 |
444 |
$8K |
| D0274 |
Bitewings - four radiographic images |
408 |
404 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
783 |
775 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
814 |
802 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
777 |
768 |
$5K |
| D0272 |
Bitewings - two radiographic images |
328 |
324 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
141 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
102 |
$1K |
| D0330 |
Panoramic radiographic image |
152 |
149 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$512.48 |
| D0603 |
|
896 |
886 |
$0.00 |
| D0602 |
|
41 |
41 |
$0.00 |
| D0601 |
|
16 |
16 |
$0.00 |