| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$4K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
140 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
135 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
145 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$352.43 |
| D0602 |
|
142 |
134 |
$0.00 |
| D0603 |
|
51 |
47 |
$0.00 |