| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
58 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
258 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
110 |
$3K |
| D1120 |
Prophylaxis - child |
100 |
96 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
96 |
88 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
28 |
$998.91 |
| D0330 |
Panoramic radiographic image |
39 |
37 |
$964.75 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
106 |
$585.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
64 |
$425.40 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$176.40 |
| D0603 |
|
549 |
539 |
$0.00 |