| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
327 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
50 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
25 |
$5K |
| D1120 |
Prophylaxis - child |
349 |
348 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
76 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
366 |
67 |
$176.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
132 |
121 |
$56.00 |
| D1206 |
Topical application of fluoride varnish |
170 |
169 |
$51.50 |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
293 |
$27.06 |
| D0272 |
Bitewings - two radiographic images |
214 |
212 |
$20.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
260 |
$4.74 |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$0.00 |