| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,155 |
386 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
24 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
16 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
474 |
413 |
$5K |
| D1206 |
Topical application of fluoride varnish |
307 |
272 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
98 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
74 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
90 |
$2K |
| D0274 |
Bitewings - four radiographic images |
90 |
79 |
$2K |
| D1351 |
Sealant - per tooth |
117 |
20 |
$2K |
| D1110 |
Prophylaxis - adult |
23 |
17 |
$729.95 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
18 |
$515.09 |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
32 |
$423.36 |
| D0603 |
|
347 |
326 |
$0.00 |