| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
90 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
94 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
19 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
88 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
111 |
111 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
140 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
100 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$600.44 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$380.71 |
| D0603 |
|
263 |
261 |
$0.00 |