| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
197 |
$26K |
| D0274 |
Bitewings - four radiographic images |
517 |
510 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
443 |
$11K |
| D1206 |
Topical application of fluoride varnish |
605 |
595 |
$8K |
| D1110 |
Prophylaxis - adult |
245 |
243 |
$7K |
| D1120 |
Prophylaxis - child |
324 |
316 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$5K |
| D0330 |
Panoramic radiographic image |
112 |
109 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
44 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
20 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
29 |
$697.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$500.00 |