| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
227 |
60 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
27 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
150 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
147 |
$3K |
| D1120 |
Prophylaxis - child |
77 |
75 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
74 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
107 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
150 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$918.32 |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$889.48 |
| D0330 |
Panoramic radiographic image |
91 |
88 |
$791.97 |
| D0350 |
|
146 |
142 |
$18.38 |
| D0603 |
|
204 |
201 |
$0.00 |