| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
644 |
285 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
623 |
298 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
959 |
957 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,192 |
868 |
$24K |
| D1120 |
Prophylaxis - child |
624 |
624 |
$22K |
| D1351 |
Sealant - per tooth |
777 |
230 |
$20K |
| D1110 |
Prophylaxis - adult |
305 |
304 |
$16K |
| D0274 |
Bitewings - four radiographic images |
414 |
414 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
948 |
946 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
866 |
$11K |
| D0272 |
Bitewings - two radiographic images |
196 |
196 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$778.95 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$379.54 |
| D0603 |
|
1,024 |
998 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$0.00 |
| D0602 |
|
32 |
30 |
$0.00 |