| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
60 |
$11K |
| D1120 |
Prophylaxis - child |
134 |
133 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
32 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
145 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
246 |
137 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
178 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
91 |
90 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
141 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
33 |
$770.66 |
| D1351 |
Sealant - per tooth |
26 |
13 |
$734.24 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0350 |
|
16 |
16 |
$220.56 |
| D0603 |
|
246 |
246 |
$0.00 |