| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
50 |
$12K |
| D1120 |
Prophylaxis - child |
123 |
110 |
$4K |
| D1206 |
Topical application of fluoride varnish |
199 |
164 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
106 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
47 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
85 |
78 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
57 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
41 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
38 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
64 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
14 |
$410.15 |
| D0603 |
|
20 |
16 |
$183.08 |