| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
56 |
$8K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
111 |
111 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
91 |
82 |
$3K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$590.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
17 |
$332.64 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
21 |
$267.03 |
| D1999 |
|
33 |
33 |
$0.00 |
| D1330 |
|
106 |
106 |
$0.00 |