| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
32 |
$6K |
| D1110 |
Prophylaxis - adult |
128 |
121 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
141 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
149 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
48 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
34 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
40 |
$939.98 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$769.75 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
55 |
$634.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
47 |
$423.18 |