| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
34 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$2K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
37 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
47 |
$922.25 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$645.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$446.46 |
| D1330 |
|
63 |
63 |
$323.24 |
| D1310 |
|
61 |
61 |
$312.61 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$148.40 |