| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
365 |
236 |
$20K |
| D1351 |
Sealant - per tooth |
980 |
248 |
$14K |
| D1120 |
Prophylaxis - child |
476 |
475 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
134 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
522 |
$8K |
| D1110 |
Prophylaxis - adult |
260 |
260 |
$7K |
| D0274 |
Bitewings - four radiographic images |
351 |
351 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
812 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
831 |
762 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$4K |
| D0272 |
Bitewings - two radiographic images |
335 |
335 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
269 |
242 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
401 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
38 |
$3K |
| D1206 |
Topical application of fluoride varnish |
311 |
311 |
$2K |
| D0330 |
Panoramic radiographic image |
201 |
201 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$847.68 |
| D0603 |
|
728 |
728 |
$0.00 |