| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
486 |
338 |
$55K |
| D1120 |
Prophylaxis - child |
347 |
347 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
387 |
$12K |
| D0272 |
Bitewings - two radiographic images |
335 |
335 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
40 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
222 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$3K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$936.55 |