| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
584 |
221 |
$57K |
| D1351 |
Sealant - per tooth |
1,723 |
326 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
1,098 |
$31K |
| D1110 |
Prophylaxis - adult |
380 |
374 |
$20K |
| D1120 |
Prophylaxis - child |
480 |
473 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,190 |
1,171 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,438 |
984 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
88 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,073 |
1,048 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
295 |
269 |
$8K |
| D0274 |
Bitewings - four radiographic images |
231 |
227 |
$8K |
| D0272 |
Bitewings - two radiographic images |
364 |
361 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
15 |
$5K |
| D0350 |
|
71 |
69 |
$801.96 |
| D0330 |
Panoramic radiographic image |
85 |
84 |
$608.14 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$282.56 |
| D0250 |
|
14 |
14 |
$238.82 |
| D0603 |
|
1,391 |
1,369 |
$0.00 |