| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
69 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
50 |
$7K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
100 |
83 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
18 |
$3K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$2K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
30 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$592.43 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
29 |
$264.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
20 |
$111.59 |