| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
42 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
27 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
91 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
62 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
48 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
93 |
90 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
45 |
$1K |
| D1110 |
Prophylaxis - adult |
22 |
19 |
$987.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
77 |
$633.05 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
78 |
$521.82 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
16 |
$433.76 |
| D0272 |
Bitewings - two radiographic images |
17 |
16 |
$327.32 |
| D0603 |
|
91 |
88 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |