| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
427 |
285 |
$74K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
424 |
378 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
115 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
254 |
172 |
$29K |
| D1120 |
Prophylaxis - child |
209 |
209 |
$13K |
| D1206 |
Topical application of fluoride varnish |
283 |
283 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$8K |
| D1351 |
Sealant - per tooth |
124 |
55 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
247 |
$5K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$4K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
148 |
$4K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
26 |
$2K |
| D0603 |
|
276 |
272 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
143 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$313.40 |
| D0180 |
|
16 |
16 |
$42.00 |
| D1310 |
|
82 |
82 |
$0.00 |
| D1330 |
|
371 |
346 |
$0.00 |