| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
276 |
$21K |
| D1351 |
Sealant - per tooth |
1,186 |
311 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
193 |
$10K |
| D1110 |
Prophylaxis - adult |
328 |
327 |
$8K |
| D1120 |
Prophylaxis - child |
476 |
474 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
587 |
585 |
$8K |
| D0274 |
Bitewings - four radiographic images |
397 |
397 |
$6K |
| D1206 |
Topical application of fluoride varnish |
794 |
791 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
88 |
88 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
372 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
55 |
$4K |
| D0272 |
Bitewings - two radiographic images |
326 |
323 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
220 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
460 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
408 |
$2K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$1K |
| D0601 |
|
145 |
145 |
$0.00 |
| D0603 |
|
550 |
549 |
$0.00 |
| D0602 |
|
242 |
241 |
$0.00 |