| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
80 |
$13K |
| D1120 |
Prophylaxis - child |
257 |
249 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
298 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
341 |
328 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
35 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
31 |
$4K |
| D0272 |
Bitewings - two radiographic images |
213 |
207 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
156 |
125 |
$4K |
| D1351 |
Sealant - per tooth |
124 |
36 |
$4K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$735.42 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
43 |
$364.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
15 |
$149.63 |
| D1999 |
|
208 |
148 |
$0.00 |
| D0603 |
|
352 |
345 |
$0.00 |
| D0602 |
|
30 |
28 |
$0.00 |