| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
107 |
39 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
272 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
115 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
49 |
$13K |
| D0330 |
Panoramic radiographic image |
99 |
86 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
33 |
$10K |
| D1351 |
Sealant - per tooth |
232 |
41 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
119 |
$8K |
| D1110 |
Prophylaxis - adult |
67 |
64 |
$5K |
| D1206 |
Topical application of fluoride varnish |
121 |
113 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
83 |
$4K |
| D0274 |
Bitewings - four radiographic images |
63 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
155 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
48 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
73 |
$930.18 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$837.77 |