| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
39 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
33 |
28 |
$2K |
| D1206 |
Topical application of fluoride varnish |
33 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
20 |
$792.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$648.00 |