| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
150 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
771 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,043 |
922 |
$20K |
| D1120 |
Prophylaxis - child |
435 |
388 |
$17K |
| D1110 |
Prophylaxis - adult |
294 |
275 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
163 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
13 |
$660.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
16 |
$651.20 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
14 |
$247.50 |
| D1999 |
|
17 |
12 |
$0.00 |
| D1330 |
|
97 |
96 |
$0.00 |