| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
77 |
$14K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
262 |
262 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
293 |
293 |
$4K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
146 |
131 |
$4K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
48 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
60 |
$915.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$902.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$98.70 |