| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
87 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
217 |
171 |
$6K |
| D1120 |
Prophylaxis - child |
156 |
156 |
$5K |
| D1206 |
Topical application of fluoride varnish |
253 |
253 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
123 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
57 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$548.76 |
| D0603 |
|
53 |
53 |
$475.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$335.39 |