| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
399 |
156 |
$38K |
| D1110 |
Prophylaxis - adult |
284 |
265 |
$14K |
| D0274 |
Bitewings - four radiographic images |
280 |
262 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
272 |
$8K |
| D1206 |
Topical application of fluoride varnish |
386 |
364 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
29 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
324 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
337 |
313 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
47 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$406.65 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$280.56 |
| D0603 |
|
443 |
415 |
$0.00 |