| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
19 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
18 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
44 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
47 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$837.90 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
29 |
$786.19 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$628.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.32 |
| D0603 |
|
102 |
102 |
$0.00 |