| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
735 |
717 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
152 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
676 |
660 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
864 |
842 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
43 |
$3K |
| D0272 |
Bitewings - two radiographic images |
519 |
503 |
$3K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
178 |
$2K |
| D1110 |
Prophylaxis - adult |
93 |
92 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
203 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
403 |
384 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
45 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
167 |
154 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
329 |
315 |
$854.90 |
| D1351 |
Sealant - per tooth |
39 |
12 |
$181.86 |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
49 |
$0.00 |