| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
276 |
$53K |
| D1110 |
Prophylaxis - adult |
630 |
625 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
183 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
662 |
$20K |
| D0330 |
Panoramic radiographic image |
226 |
226 |
$14K |
| D0274 |
Bitewings - four radiographic images |
328 |
325 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
174 |
$9K |
| D1206 |
Topical application of fluoride varnish |
451 |
448 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
44 |
$7K |
| D1120 |
Prophylaxis - child |
154 |
154 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
372 |
$5K |
| D0270 |
|
230 |
229 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
41 |
$3K |
| D9110 |
|
72 |
72 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
119 |
$2K |
| D1330 |
|
323 |
315 |
$1K |
| D0603 |
|
126 |
124 |
$890.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$504.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$352.00 |
| D0602 |
|
30 |
28 |
$215.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$162.00 |
| D1999 |
|
29 |
28 |
$0.00 |