| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
527 |
197 |
$58K |
| D1110 |
Prophylaxis - adult |
651 |
651 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,204 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,133 |
1,132 |
$22K |
| D1120 |
Prophylaxis - child |
735 |
735 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,428 |
1,428 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,210 |
1,200 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
545 |
516 |
$14K |
| D0274 |
Bitewings - four radiographic images |
303 |
303 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
40 |
$7K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$659.88 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$586.30 |