| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$820.00 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$810.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$781.25 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
18 |
$450.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$395.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
21 |
$105.01 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
20 |
$75.00 |