| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
60 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
34 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
377 |
134 |
$4K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
144 |
$4K |
| D1351 |
Sealant - per tooth |
99 |
31 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
166 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
75 |
75 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
139 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$987.84 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0603 |
|
263 |
263 |
$0.00 |