| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
161 |
161 |
$7K |
| D1206 |
Topical application of fluoride varnish |
156 |
156 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
123 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
25 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
40 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$964.96 |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$232.89 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$219.34 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$165.25 |