| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
76 |
70 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$828.10 |
| D1120 |
Prophylaxis - child |
48 |
48 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |