| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
34 |
34 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
18 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$664.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$585.00 |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$560.95 |
| D0272 |
Bitewings - two radiographic images |
29 |
28 |
$519.61 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$509.60 |
| D0603 |
|
40 |
40 |
$0.00 |