| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
80 |
$34K |
| D1120 |
Prophylaxis - child |
226 |
225 |
$17K |
| D1206 |
Topical application of fluoride varnish |
275 |
275 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
178 |
$11K |
| D1351 |
Sealant - per tooth |
108 |
31 |
$6K |
| D1110 |
Prophylaxis - adult |
57 |
55 |
$5K |
| D0240 |
|
89 |
89 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
90 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
121 |
121 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$805.81 |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$650.56 |