| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
168 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
125 |
$7K |
| D1120 |
Prophylaxis - child |
358 |
357 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
384 |
$6K |
| D1110 |
Prophylaxis - adult |
187 |
187 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
72 |
72 |
$5K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
467 |
467 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$3K |
| D0272 |
Bitewings - two radiographic images |
237 |
237 |
$3K |
| D1351 |
Sealant - per tooth |
194 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
314 |
$2K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
270 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
102 |
93 |
$1K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$360.15 |
| D0603 |
|
437 |
437 |
$0.00 |
| D0601 |
|
49 |
49 |
$0.00 |
| D0602 |
|
99 |
99 |
$0.00 |