| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
113 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
59 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
28 |
$992.25 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$988.96 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$768.32 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
61 |
$753.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$529.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
19 |
$515.09 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$303.94 |
| D0603 |
|
57 |
46 |
$0.00 |
| D0602 |
|
59 |
31 |
$0.00 |