| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
134 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
99 |
$23K |
| D0330 |
Panoramic radiographic image |
212 |
212 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
52 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
271 |
222 |
$10K |
| D1110 |
Prophylaxis - adult |
192 |
192 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
264 |
264 |
$7K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
208 |
$4K |
| D0272 |
Bitewings - two radiographic images |
205 |
205 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
81 |
$514.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
63 |
$471.96 |