| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
59 |
$6K |
| D1120 |
Prophylaxis - child |
256 |
254 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
296 |
$5K |
| D1351 |
Sealant - per tooth |
272 |
84 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
375 |
375 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
359 |
$2K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$2K |
| D0272 |
Bitewings - two radiographic images |
162 |
162 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
262 |
261 |
$2K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$956.63 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
67 |
65 |
$881.40 |
| D1206 |
Topical application of fluoride varnish |
76 |
76 |
$676.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$547.46 |
| D0603 |
|
313 |
313 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |