| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
158 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
167 |
$8K |
| D1120 |
Prophylaxis - child |
331 |
307 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
332 |
$4K |
| D1351 |
Sealant - per tooth |
340 |
77 |
$4K |
| D1110 |
Prophylaxis - adult |
165 |
151 |
$4K |
| D0274 |
Bitewings - four radiographic images |
227 |
212 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
500 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
506 |
464 |
$3K |
| D0272 |
Bitewings - two radiographic images |
226 |
207 |
$2K |
| D1206 |
Topical application of fluoride varnish |
309 |
299 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
165 |
143 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
115 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$994.56 |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
135 |
$793.80 |
| D0330 |
Panoramic radiographic image |
52 |
51 |
$364.28 |
| D0603 |
|
502 |
461 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |