| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
373 |
355 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
126 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
415 |
$9K |
| D1120 |
Prophylaxis - child |
337 |
337 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
357 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
106 |
$7K |
| D1351 |
Sealant - per tooth |
201 |
43 |
$5K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$3K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D0603 |
|
197 |
197 |
$2K |
| D1330 |
|
310 |
310 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$971.74 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$486.30 |
| D1310 |
|
14 |
14 |
$170.00 |
| D0602 |
|
12 |
12 |
$120.00 |