| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
849 |
604 |
$9K |
| D1110 |
Prophylaxis - adult |
2,329 |
2,316 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
326 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
3,566 |
3,551 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
444 |
444 |
$2K |
| D1120 |
Prophylaxis - child |
1,238 |
1,236 |
$975.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,434 |
1,407 |
$780.00 |
| D0274 |
Bitewings - four radiographic images |
1,010 |
1,006 |
$618.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,096 |
1,081 |
$357.50 |
| D1206 |
Topical application of fluoride varnish |
1,445 |
1,443 |
$141.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$52.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$0.00 |