| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
29 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
21 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
48 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
57 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
44 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
71 |
$999.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
33 |
$894.63 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
71 |
$866.64 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$865.50 |
| D0272 |
Bitewings - two radiographic images |
19 |
18 |
$420.84 |
| D0603 |
|
175 |
172 |
$0.00 |