| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
75 |
$46.28 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$40.40 |
| D1110 |
Prophylaxis - adult |
28 |
27 |
$26.92 |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
91 |
$22.77 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$17.07 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
30 |
$13.14 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
33 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
16 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |