| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
365 |
169 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
103 |
$16K |
| D1120 |
Prophylaxis - child |
512 |
493 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
550 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
639 |
610 |
$8K |
| D0330 |
Panoramic radiographic image |
127 |
121 |
$6K |
| D1351 |
Sealant - per tooth |
207 |
61 |
$4K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$3K |
| D0272 |
Bitewings - two radiographic images |
125 |
121 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
107 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
70 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
111 |
$1K |
| D0240 |
|
52 |
47 |
$846.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
17 |
$320.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$234.00 |