| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
933 |
462 |
$47K |
| D1110 |
Prophylaxis - adult |
525 |
525 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
43 |
$10K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
168 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$3K |
| D0274 |
Bitewings - four radiographic images |
354 |
354 |
$289.19 |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
404 |
$85.30 |
| D0120 |
Periodic oral evaluation - established patient |
509 |
508 |
$55.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
625 |
340 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
313 |
313 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
15 |
$0.00 |