| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
549 |
226 |
$47K |
| D1351 |
Sealant - per tooth |
1,132 |
211 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,128 |
1,103 |
$30K |
| D1120 |
Prophylaxis - child |
763 |
749 |
$27K |
| D1110 |
Prophylaxis - adult |
392 |
379 |
$19K |
| D0274 |
Bitewings - four radiographic images |
539 |
523 |
$15K |
| D1206 |
Topical application of fluoride varnish |
911 |
886 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,502 |
457 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
602 |
$5K |
| D0272 |
Bitewings - two radiographic images |
246 |
237 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
333 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$5K |
| D0330 |
Panoramic radiographic image |
154 |
152 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
39 |
$1K |
| D0603 |
|
1,748 |
1,706 |
$0.00 |
| D0602 |
|
15 |
13 |
$0.00 |