| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
59 |
$25K |
| D1120 |
Prophylaxis - child |
292 |
291 |
$12K |
| D1206 |
Topical application of fluoride varnish |
346 |
344 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
268 |
$7K |
| D0272 |
Bitewings - two radiographic images |
159 |
155 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
119 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$958.80 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$328.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$261.10 |
| D0602 |
|
13 |
13 |
$143.00 |