| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
698 |
324 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
612 |
292 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
939 |
881 |
$21K |
| D1110 |
Prophylaxis - adult |
545 |
507 |
$20K |
| D1120 |
Prophylaxis - child |
640 |
609 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,086 |
1,023 |
$19K |
| D0274 |
Bitewings - four radiographic images |
507 |
475 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
284 |
$8K |
| D0272 |
Bitewings - two radiographic images |
369 |
354 |
$6K |
| D0330 |
Panoramic radiographic image |
184 |
180 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
97 |
88 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
98 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
164 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
13 |
$966.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$126.75 |
| D1330 |
|
260 |
240 |
$0.00 |
| D0350 |
|
322 |
279 |
$0.00 |