| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
105 |
$25K |
| D1120 |
Prophylaxis - child |
522 |
520 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
286 |
285 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
541 |
539 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
235 |
228 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
207 |
206 |
$5K |
| D0272 |
Bitewings - two radiographic images |
60 |
59 |
$1K |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$545.41 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$523.36 |