| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
104 |
$31K |
| D1120 |
Prophylaxis - child |
340 |
330 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
371 |
360 |
$10K |
| D1351 |
Sealant - per tooth |
416 |
96 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
566 |
547 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
26 |
$6K |
| D0274 |
Bitewings - four radiographic images |
190 |
183 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
429 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
155 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
415 |
$5K |
| D1110 |
Prophylaxis - adult |
73 |
70 |
$4K |
| D0272 |
Bitewings - two radiographic images |
102 |
100 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
88 |
79 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
12 |
$960.90 |
| D0603 |
|
613 |
582 |
$0.00 |
| D0602 |
|
34 |
34 |
$0.00 |