| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
26 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
42 |
42 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
64 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$970.20 |
| D1351 |
Sealant - per tooth |
32 |
14 |
$903.68 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
67 |
$816.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$759.08 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$444.22 |
| D0603 |
|
97 |
97 |
$0.00 |