| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
88 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
588 |
569 |
$16K |
| D1120 |
Prophylaxis - child |
408 |
396 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
89 |
89 |
$12K |
| D1110 |
Prophylaxis - adult |
238 |
229 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
603 |
584 |
$8K |
| D0274 |
Bitewings - four radiographic images |
325 |
314 |
$8K |
| D0272 |
Bitewings - two radiographic images |
304 |
295 |
$6K |
| D1351 |
Sealant - per tooth |
144 |
30 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$4K |
| D0330 |
Panoramic radiographic image |
154 |
147 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
17 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
62 |
$2K |
| D9248 |
|
17 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
105 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
35 |
$894.63 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
63 |
$748.15 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$271.08 |
| D0603 |
|
511 |
498 |
$0.01 |
| D0602 |
|
157 |
155 |
$0.00 |
| D0601 |
|
93 |
93 |
$0.00 |