| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
45 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
31 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
109 |
$953.51 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
86 |
$874.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
93 |
89 |
$791.22 |
| D0274 |
Bitewings - four radiographic images |
33 |
32 |
$484.54 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$375.05 |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$374.08 |
| D0350 |
|
16 |
15 |
$238.94 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
21 |
$0.00 |
| D0603 |
|
100 |
95 |
$0.00 |