| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
54 |
$12K |
| D1351 |
Sealant - per tooth |
263 |
50 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
435 |
426 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
127 |
$4K |
| D1120 |
Prophylaxis - child |
157 |
155 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
426 |
220 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
240 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
26 |
$623.61 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$273.38 |
| D0603 |
|
472 |
462 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |