| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
26 |
$11K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$1K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
28 |
$878.99 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$740.74 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$672.30 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$337.68 |