| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
132 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
171 |
170 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
809 |
$23K |
| D1120 |
Prophylaxis - child |
531 |
528 |
$19K |
| D0274 |
Bitewings - four radiographic images |
520 |
516 |
$17K |
| D1110 |
Prophylaxis - adult |
296 |
295 |
$16K |
| D1351 |
Sealant - per tooth |
452 |
120 |
$12K |
| D1206 |
Topical application of fluoride varnish |
835 |
828 |
$12K |
| D0272 |
Bitewings - two radiographic images |
283 |
281 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
196 |
$6K |
| D0330 |
Panoramic radiographic image |
64 |
62 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
155 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$812.36 |
| D0601 |
|
16 |
15 |
$0.00 |
| D0603 |
|
1,005 |
997 |
$0.00 |