| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
187 |
$14K |
| D1120 |
Prophylaxis - child |
184 |
184 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
28 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$1K |
| D1351 |
Sealant - per tooth |
286 |
44 |
$920.59 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$224.22 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
98 |
85 |
$92.11 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$66.34 |
| D1206 |
Topical application of fluoride varnish |
173 |
173 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
22 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |