| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
46 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
82 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
62 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
84 |
83 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
44 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
92 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
80 |
$984.71 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$330.75 |
| D0603 |
|
115 |
114 |
$0.00 |