| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
75 |
$12K |
| D1120 |
Prophylaxis - child |
173 |
173 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
163 |
$7K |
| D1206 |
Topical application of fluoride varnish |
173 |
173 |
$6K |
| D0272 |
Bitewings - two radiographic images |
109 |
109 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
51 |
$1K |
| D0603 |
|
62 |
62 |
$610.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$210.00 |