| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
168 |
$39K |
| D1120 |
Prophylaxis - child |
954 |
942 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,136 |
1,121 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
415 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
646 |
639 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
283 |
$13K |
| D0240 |
|
619 |
309 |
$10K |
| D1351 |
Sealant - per tooth |
523 |
79 |
$8K |
| D1110 |
Prophylaxis - adult |
154 |
151 |
$6K |
| D0272 |
Bitewings - two radiographic images |
286 |
279 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
53 |
52 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
83 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$922.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
26 |
$697.64 |
| D1330 |
|
388 |
386 |
$0.00 |
| D1310 |
|
352 |
350 |
$0.00 |