| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
39 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
17 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
75 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D1120 |
Prophylaxis - child |
42 |
42 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
50 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
75 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
59 |
$679.54 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
60 |
$315.26 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$103.52 |
| D0603 |
|
88 |
86 |
$0.00 |