| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
81 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
239 |
$14K |
| D1206 |
Topical application of fluoride varnish |
425 |
424 |
$12K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$9K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$7K |
| D1120 |
Prophylaxis - child |
190 |
189 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
121 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
53 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
17 |
$727.00 |