| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$952.00 |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$800.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$288.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$272.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$171.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$0.00 |