| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
44 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
237 |
209 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
355 |
355 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
221 |
$4K |
| D1120 |
Prophylaxis - child |
98 |
98 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$898.02 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
48 |
$751.42 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$749.84 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$522.72 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$369.04 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$203.04 |