| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
719 |
330 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
1,617 |
1,617 |
$45K |
| D1110 |
Prophylaxis - adult |
790 |
790 |
$42K |
| D1120 |
Prophylaxis - child |
876 |
876 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,562 |
1,562 |
$23K |
| D0274 |
Bitewings - four radiographic images |
654 |
654 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
172 |
$12K |
| D0272 |
Bitewings - two radiographic images |
682 |
682 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
65 |
$8K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
140 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
14 |
$515.09 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$125.60 |
| D0603 |
|
1,793 |
1,791 |
$0.00 |
| D0602 |
|
35 |
35 |
$0.00 |