| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
160 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
349 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
63 |
$19K |
| D1110 |
Prophylaxis - adult |
279 |
268 |
$19K |
| D1206 |
Topical application of fluoride varnish |
499 |
479 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
393 |
$17K |
| D1120 |
Prophylaxis - child |
243 |
231 |
$12K |
| D0330 |
Panoramic radiographic image |
122 |
106 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
37 |
$7K |
| D0274 |
Bitewings - four radiographic images |
117 |
111 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
180 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
82 |
$5K |
| D1351 |
Sealant - per tooth |
90 |
13 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$598.00 |
| D9215 |
|
1,065 |
861 |
$0.00 |