| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
558 |
278 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
222 |
219 |
$15K |
| D1351 |
Sealant - per tooth |
1,079 |
265 |
$14K |
| D1120 |
Prophylaxis - child |
674 |
671 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
715 |
$11K |
| D1110 |
Prophylaxis - adult |
317 |
312 |
$9K |
| D1206 |
Topical application of fluoride varnish |
947 |
945 |
$7K |
| D0274 |
Bitewings - four radiographic images |
381 |
377 |
$7K |
| D0272 |
Bitewings - two radiographic images |
482 |
479 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
272 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
345 |
306 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
597 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
565 |
544 |
$3K |
| D0330 |
Panoramic radiographic image |
206 |
203 |
$2K |
| D0603 |
|
821 |
813 |
$0.00 |
| D0602 |
|
264 |
263 |
$0.00 |
| D0601 |
|
73 |
73 |
$0.00 |