| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
134 |
134 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
81 |
$8K |
| D1206 |
Topical application of fluoride varnish |
371 |
371 |
$6K |
| D1351 |
Sealant - per tooth |
340 |
100 |
$6K |
| D1120 |
Prophylaxis - child |
255 |
255 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
303 |
303 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
123 |
$4K |
| D0272 |
Bitewings - two radiographic images |
230 |
230 |
$4K |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
48 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
97 |
$3K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
194 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$1K |
| D9996 |
|
21 |
21 |
$820.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$636.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$457.00 |
| D0240 |
|
13 |
13 |
$97.00 |