| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
39 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
135 |
$7K |
| D1120 |
Prophylaxis - child |
167 |
138 |
$5K |
| D1206 |
Topical application of fluoride varnish |
286 |
239 |
$5K |
| D1110 |
Prophylaxis - adult |
112 |
87 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
101 |
97 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
17 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
38 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
74 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
15 |
$483.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
32 |
$451.28 |
| D0272 |
Bitewings - two radiographic images |
16 |
12 |
$323.52 |