| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
375 |
368 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
27 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
467 |
455 |
$7K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$4K |
| D0274 |
Bitewings - four radiographic images |
118 |
116 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
56 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$635.76 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$537.74 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$302.42 |
| D0602 |
|
380 |
367 |
$0.00 |