| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
92 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
122 |
114 |
$15K |
| D1120 |
Prophylaxis - child |
398 |
371 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
278 |
$9K |
| D0330 |
Panoramic radiographic image |
176 |
162 |
$8K |
| D1351 |
Sealant - per tooth |
458 |
103 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
502 |
468 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
679 |
352 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
199 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
367 |
$3K |
| D0274 |
Bitewings - four radiographic images |
150 |
134 |
$3K |
| D0272 |
Bitewings - two radiographic images |
161 |
153 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
77 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$548.80 |
| D1206 |
Topical application of fluoride varnish |
16 |
13 |
$161.70 |
| D0603 |
|
788 |
740 |
$0.00 |