| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
163 |
$13K |
| D1120 |
Prophylaxis - child |
549 |
544 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
645 |
640 |
$9K |
| D1110 |
Prophylaxis - adult |
287 |
284 |
$8K |
| D1351 |
Sealant - per tooth |
682 |
110 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
127 |
$7K |
| D1206 |
Topical application of fluoride varnish |
842 |
834 |
$6K |
| D0274 |
Bitewings - four radiographic images |
322 |
320 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$5K |
| D0272 |
Bitewings - two radiographic images |
410 |
409 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
189 |
$3K |
| D0330 |
Panoramic radiographic image |
192 |
188 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
361 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
318 |
286 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$694.85 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
30 |
$433.92 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$140.85 |
| D0601 |
|
55 |
55 |
$0.00 |
| D0603 |
|
754 |
745 |
$0.00 |
| D0602 |
|
66 |
66 |
$0.00 |