| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
163 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
527 |
526 |
$14K |
| D1120 |
Prophylaxis - child |
386 |
386 |
$13K |
| D1110 |
Prophylaxis - adult |
229 |
228 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
297 |
263 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
364 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
43 |
$6K |
| D0272 |
Bitewings - two radiographic images |
293 |
292 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
320 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
274 |
262 |
$3K |
| D1206 |
Topical application of fluoride varnish |
101 |
101 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$990.00 |