| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
830 |
270 |
$41K |
| D1351 |
Sealant - per tooth |
2,071 |
375 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
300 |
298 |
$20K |
| D1110 |
Prophylaxis - adult |
730 |
727 |
$20K |
| D1120 |
Prophylaxis - child |
1,061 |
1,058 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,292 |
1,286 |
$18K |
| D0274 |
Bitewings - four radiographic images |
822 |
818 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,465 |
1,458 |
$10K |
| D0272 |
Bitewings - two radiographic images |
809 |
807 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
504 |
$8K |
| D0330 |
Panoramic radiographic image |
503 |
502 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
29 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
664 |
653 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
527 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
241 |
217 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
165 |
165 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$328.65 |
| D0603 |
|
1,783 |
1,779 |
$0.00 |
| D0601 |
|
62 |
62 |
$0.00 |
| D0602 |
|
185 |
184 |
$0.00 |