| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,186 |
1,063 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,676 |
837 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
5,008 |
4,084 |
$102K |
| D1120 |
Prophylaxis - child |
3,304 |
2,761 |
$102K |
| D1110 |
Prophylaxis - adult |
1,900 |
1,633 |
$85K |
| D1206 |
Topical application of fluoride varnish |
5,009 |
4,034 |
$76K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,458 |
1,090 |
$51K |
| D0330 |
Panoramic radiographic image |
525 |
448 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
427 |
150 |
$25K |
| D0274 |
Bitewings - four radiographic images |
611 |
528 |
$19K |
| D0272 |
Bitewings - two radiographic images |
932 |
757 |
$18K |
| D1351 |
Sealant - per tooth |
705 |
67 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
300 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
25 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
63 |
$5K |
| D0350 |
|
260 |
222 |
$4K |
| D2330 |
|
68 |
26 |
$3K |
| D9248 |
|
29 |
25 |
$3K |
| D1354 |
|
71 |
17 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
62 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
27 |
$462.00 |
| D1320 |
|
15 |
12 |
$343.97 |
| D1999 |
|
258 |
94 |
$0.00 |