| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
209 |
$15K |
| D1120 |
Prophylaxis - child |
613 |
612 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
206 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
589 |
587 |
$9K |
| D1110 |
Prophylaxis - adult |
241 |
239 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
729 |
727 |
$5K |
| D0274 |
Bitewings - four radiographic images |
293 |
291 |
$5K |
| D0272 |
Bitewings - two radiographic images |
399 |
399 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
269 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
58 |
58 |
$4K |
| D0330 |
Panoramic radiographic image |
190 |
189 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
184 |
176 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
341 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
270 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
16 |
$1K |
| D1351 |
Sealant - per tooth |
70 |
15 |
$960.16 |
| D1206 |
Topical application of fluoride varnish |
85 |
85 |
$624.75 |
| D0603 |
|
609 |
607 |
$0.00 |
| D0602 |
|
268 |
268 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |