| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
273 |
159 |
$22K |
| D1120 |
Prophylaxis - child |
721 |
721 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
992 |
992 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,115 |
1,115 |
$15K |
| D1320 |
|
385 |
375 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
706 |
700 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
368 |
358 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,259 |
533 |
$8K |
| D1110 |
Prophylaxis - adult |
196 |
196 |
$8K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$541.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$338.40 |