| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
41 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
344 |
315 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
806 |
346 |
$7K |
| D1120 |
Prophylaxis - child |
242 |
223 |
$7K |
| D1206 |
Topical application of fluoride varnish |
364 |
336 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
385 |
$4K |
| D1351 |
Sealant - per tooth |
248 |
44 |
$4K |
| D0274 |
Bitewings - four radiographic images |
60 |
57 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
24 |
$437.46 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$298.21 |
| D0603 |
|
370 |
344 |
$0.16 |
| D0602 |
|
29 |
29 |
$0.01 |
| D0601 |
|
13 |
13 |
$0.01 |