| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
66 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
41 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
124 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$3K |
| D2950 |
|
20 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$2K |
| D0330 |
Panoramic radiographic image |
60 |
59 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
62 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
106 |
94 |
$924.15 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$436.57 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
33 |
$410.59 |