| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
95 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
30 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
148 |
$5K |
| D1120 |
Prophylaxis - child |
85 |
84 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
183 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
85 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
70 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$899.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$361.53 |
| D0603 |
|
220 |
218 |
$0.00 |