| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
812 |
552 |
$56K |
| D1120 |
Prophylaxis - child |
1,617 |
1,604 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,090 |
2,075 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,300 |
2,290 |
$43K |
| D1110 |
Prophylaxis - adult |
852 |
849 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
592 |
429 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,040 |
973 |
$29K |
| D0330 |
Panoramic radiographic image |
275 |
274 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
94 |
$10K |
| D0274 |
Bitewings - four radiographic images |
347 |
346 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
296 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$1K |
| D2330 |
|
17 |
12 |
$880.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
37 |
$466.25 |
| D1330 |
|
2,408 |
2,394 |
$0.00 |