| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
18 |
$723.06 |
| D1351 |
Sealant - per tooth |
119 |
21 |
$508.32 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
17 |
$421.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
31 |
$105.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
22 |
$54.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
16 |
$44.10 |
| D1120 |
Prophylaxis - child |
19 |
16 |
$36.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
29 |
$34.53 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
29 |
$25.12 |
| D0603 |
|
110 |
104 |
$0.24 |
| D0350 |
|
18 |
16 |
$0.00 |