| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
217 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
727 |
705 |
$28K |
| D1120 |
Prophylaxis - child |
759 |
737 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
104 |
$13K |
| D1206 |
Topical application of fluoride varnish |
605 |
577 |
$12K |
| D1351 |
Sealant - per tooth |
400 |
66 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
152 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
29 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
40 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
118 |
$5K |
| D0274 |
Bitewings - four radiographic images |
126 |
120 |
$3K |
| D0350 |
|
62 |
60 |
$1K |
| D0330 |
Panoramic radiographic image |
61 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
101 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
30 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
14 |
$66.80 |
| D1330 |
|
62 |
61 |
$0.00 |