| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
122 |
$45K |
| D1110 |
Prophylaxis - adult |
179 |
162 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
235 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
155 |
$8K |
| D0272 |
Bitewings - two radiographic images |
236 |
232 |
$6K |
| D0330 |
Panoramic radiographic image |
163 |
160 |
$6K |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
15 |
$5K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
113 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
192 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
98 |
$965.32 |
| D0999 |
Unspecified diagnostic procedure, by report |
474 |
213 |
$0.00 |