| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
97 |
$13K |
| D1206 |
Topical application of fluoride varnish |
612 |
610 |
$13K |
| D1120 |
Prophylaxis - child |
511 |
511 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
318 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
180 |
154 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
200 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$3K |
| D1351 |
Sealant - per tooth |
132 |
37 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$2K |
| D0272 |
Bitewings - two radiographic images |
184 |
184 |
$1K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$580.40 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$456.00 |
| D0240 |
|
24 |
13 |
$154.00 |